Site Survey Form Company Name Contact Name First Last Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country PhoneEmail Substrate ConditionsProject Name Sq Feet of Area (Attach Drawing if Possible) FileMax. file size: 128 MB.Which Type? Elevated Slab Slab-On-Grade Area Usage (Warehouse, Production, etc) Type of Substrate Condition of Substrate (Oily, Eroded, Damp, etc) Are floor repairs needed? Yes No If yes, please describe (indicate quantity and/or size repairs):Are any cracks visible? Yes No Lineal Feet & Width Does Substrate have an existing sealer or coating? Yes No Type (if known - Cure-n-Seal, Epoxy, etc) Additional RequirementsFloor Drains? Yes No Number & Size of Drains: Cove Base? Yes No Lineal Feet & Height: Lineal Feet & Height: Lineal Feet & Height: Joints to be filled? Yes No Lineal Feet & Height: Slip Resistance: Calcium Chloride Testing Results (lbs / 1000 sq ft) RH (%) Surface Exposure / UseExtreme Heat or Cold / Temperature Range:Minimum (degrees Farenheit) Maximum (degrees Farenheit) Constant Cycles Chemicals (please supply list of chemicals, % solutions, ambient or elevated temperatures)Frequency of chemical exposure:Constant Yes No Splash & Spill Yes No Occasional Yes No Traffic (foot, lift trucks, other) Immersion (by water or other) Project ConditionsIs this for a shut-down? Yes No Is this: Interior Exterior Expected temperatues during installation:Substrate (degrees Farenheit) Ambient Air (degrees Farenheit) Availability: Monday Tuesday Wednesday Thursday Friday Weekends Work hours available (starting from, finishing at) How soon does customer need use of floor after installation completed ? Other trades working in area during installation? Yes No Environmental Concerns:Odor Yes No Dust Yes No Vibration Yes No Other ConsiderationsAny additional project notes?EmailThis field is for validation purposes and should be left unchanged. Δ
