Customer Name: Address: City: State: Zip: Phone: Fax: E-mail Address: Contact: 1. Description of application (include type of equipment plus description of system): 2. Hose type and Size CH67 Medium Pressure Teflon CH60 High Pressure Teflon CH61 Ultra High Pressure Teflon CH68 Convoluted Teflon CH92 Corrugated Metal Unknown Hose Type Pick the hose size to match your hose type: CH67 0.125 0.187 0.250 0.312 0.406 0.500 0.625 0.875 1.125 1.375 CH60 0.222 0.308 0.401 0.495 0.617 0.867 1.125 1.375 CH61 0.229 0.300 0.395 0.525 0.650 0.875 CH68 0.375 0.500 0.625 0.750 1.000 1.250 2.000 3.000 4.000 CH92 0.250 0.375 0.500 0.750 1.000 1.250 1.500 1.750 2.000 3.000 4.000 (If size is unknown, specify fluid/material and flow rate) 3. Fitting requirements (size, material, type): Input end: JIC Female NPT Male NPT Female Tube Stub Other Output end: JIC Female NPT Male NPT Female Tube Stub Other 4. Overall length: 5. Heater requirements: Volts: Watts: 6. Temperature sensor: RTD T/C J T/C K Other Sensor Qty: 7. Pressures: PSI Max Operating 8. Vacuum: Yes No 9. Hose outer cover: Type: Type: Braided Polyester Extruded Silicone High Temperature other Color: 10. Material being conveyed and heated: 11. Material temperatures: °F Max ° F Min ° F Operating °F Ambient Environment: Indoor Outdoor 12. Hose Bend Radius: Static bend radius: Flexing application bend radius: 13. Misc. notes:

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