© 2017 Justrite Mfg. Co. Code No. 165 (10/17)
Don’t see what you need in Justrite’s line of readily
available emergency equipment? Let our team design a
custom solution to meet your specic requirements. As
part of Justrite, Hughes Safety Showers group has more
than 45 years of experience in meeting deadlines and
design standards for any new build or site refurbishment
project. They provide safety pre-sales consulting to
ensure projects are completed smoothly, on schedule,
and in compliance with ANSI. Offering expertise, advice,
and technical support throughout all stages of your
custom shower project, We empower you to make the
best decisions for achieving your company’s safety goals.
Describe what you are looking for in your safety shower, including quantity desired. If you have specications,
such as a Request for Quote (RFQ), Master Document Register (MDR), or Supplier Document Register (SDR),
please submit along with this form. If you are unsure of what you need, please answer the questions in the next
section to the best of your knowledge.
I KNOW WHAT I WANT.
Custom Safety Shower Form
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WE’RE HAPPY TO HELP
Please complete the questions on the following page.
NOT SURE WHAT I NEED.
Company Name
Phone
Email
Name
End User:
Custom shower orders are non-cancelleable and non-returnable.
Phone
Email
Name
Account No.
Company Name
Distributor:
REQUIRED INFORMATION:
Sales/Rep Contact
BDS Contact
For Internal Use Only:
Distributor Name: End User Name:
Answer as many questions as you can so we can begin our discussions.
HELP ME DETERMINE THE BEST PRODUCT FOR MY APPLICATION.
Is there a drain near the location of the shower to route spent water?
o
Yes
o
No
1. CLIMATE
2. AVAILABILITY OF WATER
What is the ambient temperature of the location where the shower will be installed? Choose from climate/locations below:
ANSI requires water delivered by emergency safety equipment should be tepid, between 60-100°F (16-38°C).
What best describes your condition(s)?
o
Applications not subject to freezing or overheating
o
Applications subject to freezing, 32°F (0°C) or below
o
Applications subject to overheating, 100°F (38°C) or above
o
Unsure or other
o
Plumbed in, unheated water source is available
o
Plumbed in, heated water source is available
o
Water supply is not available
o
Water source is available but supply pressure is inconsistent or weak
o
Unsure or other
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Custom Safety Shower Form
Note: ANSI recommends 30 PSI minimum supply pressure. Supply pipe must be bigger than or equal to the water inlet
on equipment, otherwise the water ow will be inadequate.
o
Alarm package
o
Integrated drain sump
o
Walk on foot-panel operation
o
Strip screens
o
Doors
o
GRP paneling
o
Sun shields
o
Water treatment module
o
Chiller unit
o
Lighted sign box
o
Immersion heater
o
Unsure which options are needed
3. COMMON TANK SHOWER CUSTOMIZATION OPTIONS (Ask about others)
o
120V
o
240V
o
480V
o
50Hz
o
60Hz
4. ELECTRICAL VOLTAGE REQUIREMENTS (If applicable)
What are the voltage requirements for your application?
What are the Hertz requirements?
o
ANSI Z358.1-2014
o
OSHA 1910.151
o
EN15154
o
Unsure
7. COMPLIANCE REQUIREMENTS
Click Here to submit via email to Justrite business development
Fax: 1-800-488-5877 Email: bds@justritemfg.com
(“Click Here” button will prompt you to choose email preference)
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5. ELECTRICAL AREA CLASSIFICATION (Where applicable)
Does the area where the shower will be located have specic risks, i.e. gases or materials that can combust if there
is a spark from electrical equipment? What is your electrical area classication?
o
Class 1 Division 2
o
General Purpose
o
Unsure or other
o
Special water inlet requirements
o
Special instrumentation requirements
o
Tagging and nameplate requirements
o
Special drain requirements
6. OTHER CUSTOM OPTIONS
Custom Safety Shower Form
