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Contact Information
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Last Name *
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Company
Positions
Type of Business
Phone
Address
City
State
Zip Code
Exposure Conditions
Name of Area
Floor Exposed to	Corrosion Water Impact Wear Oil &/or Grease Vibration Other
Chemical (Concentration & Temperatures)
....
Floor Traffic	Foot Cart Truck
List weight
Type of Wheels	Steel Rubber Composition
Size of Wheels
Imperfections	Chipped Rutted Cracked
Other Imperfection
Structure Movement
How is Floor cleaned
Floor Temperature during Production
Description of Application
Dimension
Total Sq-ft.
Coving
LF Height
Curb / Vertical
LF Height
Type of Substrate	Concrete Wood Wood Other
Type of Topping to be removed (Sq-ft. thickness	Resinous flooring Concrete Patch Paint Sealer Tile Asphalt Oil & Grease Metal Wood Other
Is substrate under topping	Flat Sloped to Drain
Is drainage/pitch be deleted	Yes No
Surface Condition
Small Agg. Exposed
Large Agg. Exposed
Age of Current Floor
Floor System Desired
Alternate Flooring
Color
Alternate Color
What is the desired Texture of Floor
Site and Floor Application condition
Job Access	Dock Ground Floor Upper Floor Freight Elevator
Area is	Indoor Outdoor
Temperature of Floor during Application and Cute
Describe any Obstructions
Work to be Done	Weekday Weekend Holiday Shutdown
Total Time Available for Application and Cure
Surface Preparation	Detergent Scrub Shotblast Scarify Etch
Dust allowed	None Moderate Heavy
Removal by Jackhammer (Sq-Ft)
Removal by Scabber (sq-ft)
Keying	Yes No
Total Linear Feet
Drain Trench	0 1 2 3 4 5 6 7 8 9 10 or more
Type of Drain or Trench
Water Temperature
Water Pressure (PSI)
Compressed Air (PSI)
Compressed Air (CFM)
Electricity	110Vac 60hz 220Vac 60Hz
Lift Truck Available	Yes No
Disposal of Debris	On-site Off-site Other
Solvent
Safety
General Notes