SureSite® ViSual indicatorS - Miniature Size, alloy Product Check List This is a Request for a Quote Order P.O.#_______ Quantity Needed _____________ Photocopy This Form Use one form for each product type you are selecting. This form may also be completed online at gemssensors.com for RFQ. Date Required ____/____/_____ Shipping Method:_____________ Partials Accepted: Yes No Company _________________________________________ Street ___________________________________________ City________________________ State_____ Zip__________ Phone ( _____ ) ___________________________________ Fax ( _____ ) ______________________________________ SureSite Indicators, Alloy Versions - Miniature Size Process Conditions This information is essential to the accurate and proper operation of your SureSite® Visual Level Indicators. Please complete fully and accurately. 1. Pressure: Operating __________ psig Maximum ________ psig 4. Specific Gravity @ Operating Condition: ____________________ 2. Temperature: Operating ________ °F Maximum __________°F 5. Viscosity: _________________ SSU 3. Liquid Media: _________________________________________ 6. Application Location: Indoors Outdoors Physical Configuration 1. Mounting Configuration Types: Type AM Type BM Type CM Type DM 2. Connection Codes - Complete all 4 connection code lines. Check off NPT or Flange size where appropriate. Connection Code Number Goes Here. Connection Code Numbers and their descriptions are on Page D-5. Top T Side Sa Side Sb Bottom B NPT or Weld Flange 1/2˝ 3/4˝ Other _____________ 1/2˝ 3/4˝ 1˝ 150# RF 300# RF Other _____________ Other _____________ NPT or Weld Flange 1/2˝ 3/4˝ Other _____________ 1/2˝ 3/4˝ 1˝ 150# RF 300# RF Other _____________ Other _____________ NPT or Weld Flange 1/2˝ 3/4˝ Other _____________ 1/2˝ 3/4˝ 1˝ 150# RF 300# RF Other _____________ Other _____________ NPT or Weld Flange 1/2˝ 3/4˝ Other _____________ 1/2˝ 3/4˝ 1˝ 150# RF 300# RF Other _____________ Other _____________ 3. Length of Visual Indication - L: _____ inches (240˝, Max.). Connection to Connection Dimension - C to C: ________ inches. 4. Flag Type Plastic flags available to 300°F (149°C). Aluminum flags only for temperatures to 750°F (399°C). Plastic (Orange and White) Aluminum (Black and Silver) Non-Standard; Specify:____________________ , consult factory. Accessories (Pages D-16 to D-18) 1. Switch Modules (Single Point): _________ Quantity a. SPST SPDT DPDT 120 VAC DPDT 24 VDC b. Standard - 300°F High Temperature Explosion Proof 2. Indicating Scales: Feet and Inches Inches Metric Blank Custom Graduations; specify: _______________________ 3. Continuous Transmitter: Output: 0-5 VDC 0-12 VDC 4-20 mA J-Box: Standard Explosion Proof D-6 Name ___________________________________________ 5. O-Ring Material: Viton® (Standard) Ethylene Propylene Other ________________________________________________ Special Instructions (Materials, Connections, etc.) Please contact GEMS Sensors Inc. for any configuration or special requirements not covered on this form. 800-378-1600 Quote $ _____________________ Visit www.GemsSensors.com for most current information. Date Quoted ____/____/____ Mini SureSite / p3of3 / 3-APR-14http://ecatalog.gemssensors.com/ecatalog/configurators/Mini-SureSite