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BUCKET CONVEYOR
                                                                       QUESTIONNAIRE




              Client Name _________________________________________________________________________

              Address ____________________________________________________________________________

              Contact Name ___________________________________________   Position   __________________

              Phone _______________________________________    Fax _________________________________

              E-Mail _______________________________________   Date _________________________________

              NATURE OF MATERIAL
              Product Name or Description _______________________________________   Wt./Cu. Ft.  _________

              Particle Size (if lumpy, state max. size; if dusty, how many microns)    ___________________________
              Is product    Free-flowing?    Abrasive?    Corrosive?    Deliquescent?    Hygroscopic?    Sticky?
              Is product    Hot?   Cold?  Temp _____________    Wet?   Dusty?    Fragile?    Static?
              Is any fat or oil present?   Yes    No (If possible, send a small sample in an airtight container for inspection.)
              Can these conditions ever vary?    Yes     No

              THROUGHPUT REQUIREMENTS
              State type of feed, i.e. controlled or flood feed from bin or hopper   _____________________________
              What is the equipment feeding and what is expected of it? ______________________________________
              If feeding is continuous, state rate per hour:  Min. __________  Max. _________   Hrs. usage/day_____
              If feeding is intermittent, state max. rate per hour: _________   and operation cycle ________________
              Number of infeed positions __________________   Number of discharge positions_________________

              CONSTRUCTION MATERIALS AND FINISH
              Case construction    Carbon Steel     Stainless Steel   If stainless steel, indicate type: ____________
              Bucket type:    Polypropylene     Carbon steel     Stainless Steel     Other ____________________
              Chain type:      Carbon steel       Stainless Steel     Polyacetal     Other ______________________
              Construction type:     Folded     Tubular     Other _________________________________________
              Enclosure:    Open (will be enclosed to 7'-0" elevation for safety)     Weather proof    Explosion proof
                                   Fully enclosed (indicate cover material):   Carbon steel    Stainless steel    Lexan
              Specify finish:    Steel-It®     Enamel     Bare     Polished     Other_________________________
              Are roof or floor supports required?    Yes     No (If yes, indicate height requirements) ____________

              DRIVE
              Electrical supply details:  Voltage _______________   Phase _______________   Hz_______________
              Enclosure type:    Drip proof     Totally enclosed     Washdown     Explosion proof     NEMA ____

              Are controls required?    Yes     No
              Site address, if different from above: ____________________________________________________
               ___________________________________________________________________________________

              Please fax to Gough Econ, Inc.  704-392-8706, attn: Sales Department
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