Job Quote Request
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JOB QUOTE REQUEST
INSTRUCTIONS:
1.
Please fill‐in as much information as requested.
2.
If you are using at least Adobe 9 or Adobe X Reader, you can save this document and send it as an attachment to jobquote@cyame.com
3.
Otherwise, please print form and fax it to 1‐510‐659‐9019
A.
TYPE OF TEST
Annual Medical Gas Testing
What type of test are you requesting for?
B.
REQUESTOR’S INFORMATION
First Name
Company/Facility
Last Name
Address 1
Title
Address 2
Department
City
California
Phone number
State
Fax number
Zip code
Email address
Best way to reach you
Phone Email Both
C.
CONTACT PERSON AT THE FACILITY
SAME AS ABOVE (If checked, no need to fill‐in the following information)
First Name
Company/Facility
Last Name
Address 1
Title
Address 2
Department
City
California
Phone number
State
Fax number
Zip code
Email address
D.
FACILITY INFORMATION
Oxygen
Medical Air
Waste Evac
Carbon Dioxide
Other:
1.
What are the Medical Gases to be tested?
Check all that applies
Vacuum
Nitrous Oxide
Nitrogen
Instrument Air
DISS
Oxequip
Others:
(Threaded)
2.
Number of Outlets
Chemetron
Puritan Bennett
Enter the number of each Quick Connect
Others:
(Latch)
(Geometric)
Style you have
Ohio/Ohmeda
Schrader
Others:
(Pin Indexed)
3.
Number of Zone Valves
4.
Number of Alarm Panels
Area Alarm
Master Alarm
Combination
Enter the number of each type
Panel
Panel
Area/Master
5.
Number of Bulk Cryogenic Liquid Systems
Oxygen
Nitrous Oxide
Nitrogen
Enter the number of each type
6.
Number of Source Supply Systems
Instrument
Waste
Vacuum
Medical Air
Enter the number of each type
Air
Evacuation
Oxygen
Nitrous Oxide
Carbon Dioxide
7.
Number of Manifolds
Enter the number of each type
Medical Air
Nitrogen
8.
Number of Low Pressure Emergency
Oxygen Supply Connection (EOSC)
9.
Continue to:
E for Annual Medical Gas Testing,
F for Remodel or New Construction Certification,
G for Annual Repair
For other types of test, continue to H to include a brief description/scope‐of work
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Parent category: Business