SQURTS Submittal

SQURTS Test Item Online Submittal Form

= = = 2/6/2012 = = =

1) The submittal form must include the required catalog literature and any specific details for mounting & wiring.
2) The test samples must arrive at QualTech a minimum of one week prior to the test week. Test samples may be sent in early. Test samples received after this date will be scheduled in the next SQURTS test week.

Utility / Contact Information

Sponsoring Utility / Organization:

Will Witness Test:

Yes

Will Serve as SQURTS Test Rep.:

Yes

Address:

Contact Name:

Alternate Contact:

Phone:

Fax:

Email:

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Test Specimen Information (attach catalog info below under File Attachments)

Manufacturer:

Model / Series #:

Number of Specimens:

Part Description:

Supplied By:

Utility

QualTech

Purchased From:

OEM

OES

Dedicated By:

Utility

QualTech

Custom Fixt./Provided By:

N/A

QualTech (send sketch)

Utility

Use Location:

Safety Function:

Structural Integrity Only

Pressure Integrity Only

Full Functional Requirements

Addnl. Safety Function Info:

Pre-Conditioning:

@ QualTech

Yes

Is this item being tested
to address operability?

Yes

Seismic Test Level Requirements (attach site specific spectra below under File Attachments)

Fragility - use SQURTS 14G generic (including margin)

Fragility - use SQURTS Floor Response

Site Specific - (requires separate seismic testing)

Comments:

Seismic Interface Requirements

Orientation:

Mounted to vertical wall with nameplate controlling orientation.

Mounted to horizontal fixture/table.

Other:

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Hardware:

As provided by OEM.

As provided by utility.

Commercial grade bolt/lock washer/flat washer/nut as controlled by threaded holes/clearance holes with details to be documented in the Qualification Report.

Other:

Other Consid. / Comments:

File Attachments