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Form Filled By:
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Application Form
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Company Name:
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Date:
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Address:
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City:
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State:
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Zip:
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Contact:
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Title:
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Phone:
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Email:
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Notes:
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Product Information
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Product
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Viscosity
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Batch Size
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Other Info
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Wetted Parts (Select all compatible materials)
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304SS
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Brass
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KalRez (or equiv.)
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Viton
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316SS
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Hard Chromed
Steel
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Polypropylene
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Zinced Mild Steel
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Aluminum
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Hastelloy
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PVC
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Anodized Aluminum
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Nylon
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Teflon
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Container Information/Performance Parameters
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Size
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Style
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Lid/Cap
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Construction
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CPM
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Accuracy
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Machine Preferences
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Filling Method:
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Frame Construction:
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Operation:
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Electrical:
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Fill Type:
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Hazardous Class:
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Fill Carts:
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Closer Type:
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Product Supply
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Product Feed:
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Tank Size/Volume:
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Pump Type:
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Tank/Filler Distance:
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Pump Size:
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Tank Outlet Size:
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Pump Distance from Filler:
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Tank Outlet Height:
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Options
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Miscellaneous
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DFS
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Accumulation
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Flush Trough
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Lid Placer
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Hinged Tank Cover
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In
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Out
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Fume Vent
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Nitrogen Cont. Purge
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Nitrogen Tank Purge
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Gravity Conv.
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Guard-Fixed
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No Lid Sensor
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Power Height Adj.
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Powered Conv.
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Guard-Interlocked
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Remote Flush
Cont.
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Sprayballs
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Rotary Table
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Hand Capper
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DisperseTech LLC
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700 Conshohocken State Rd
l Penn Valley, PA 19072
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610-668-9500 l CELL: 215-806-1538
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E-Mail: steve@dispersetech.com / Website: www.dispersetech.com
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