Customer Mix Submittal Expeditor
Step 1:
On this page you must fill out all the fields with a (
*
)
Customer Information
Today's Date: 1/7/2009
*
First Name:
*
Last Name:
*
Company Name:
*
Request By:
*
Phone:
*
Fax:
*
Email:
Project Information
*
Project Name:
*
Project Address:
*
Project City:
Cross Street:
Customer Job#:
General Contractor:
Engineer:
Submittal to be reviewed by:
Sales Rep:
Quote #:
Total Yards:
--N/A--
Less Than 50
50 to 150
150 to 500
500 to 1500
1500 to 5000
More Than 5000
Note:
Mix Specifications
1.
*
Yards
*
Strength:
W/C:
*
Slump:
Min. Cem:
*
Uses:
Other Mix Requirements:
(eg: fibers, color)
Placement:
Pump Line Size:
--N/A--
4
3
2.5
2
Pumping Distance: :
--N/A--
Less Than 100
100 to 150
150 to 200
200 to 250
More Than 250
Machine:
NO
YES
Tailgate:
NO
YES
Other Placement Considerations/ Comments:
2.
*
Yards
*
Strength:
W/C:
*
Slump:
Min. Cem:
*
Uses:
Other Mix Requirements:
(eg: fibers, color)
Placement:
Pump Line Size:
--N/A--
4
3
2.5
2
Pumping Distance: :
--N/A--
Less Than 100
100 to 150
150 to 200
200 to 250
More Than 250
Machine:
NO
YES
Tailgate:
NO
YES
Other Placement Considerations/ Comments:
3.
*
Yards
*
Strength:
W/C:
*
Slump:
Min. Cem:
*
Uses:
Other Mix Requirements:
(eg: fibers, color)
Placement:
Pump Line Size:
--N/A--
4
3
2.5
2
Pumping Distance: :
--N/A--
Less Than 100
100 to 150
150 to 200
200 to 250
More Than 250
Machine:
NO
YES
Tailgate:
NO
YES
Other Placement Considerations/ Comments:
For Additional Mixes:
Specification Information Provided (check all included)
Sections:
Pages from plans (e.g: S1):
Other:
Please Attach Specification Documents:
3
I,
agree that the submittal I'm requesting will be developed from the information provided in the specifications and/or job information I have provided above. I understand that Central Concrete will not be responsible for non-conformance of submittal material that was based on inaccurate or incomplete project information provided with this submittal request.
Signed:
Date:
*
If faxing or mailing please sign and date.
*
If submitting online, the sender's e-mail address will be a valid signature.
centralqa@us-concrete.com
Ph:408 404-1030
Fax:408 404-1115
755 Stockton Ave.
San Jose,CA 95126
?Copyright 2005. All Rights Reserved. Central Concrete.com
.
