WARRANTY EVALUATION REQUEST

SFO-Seneca Falls Operations Phone (315) 568-7468 Fax: (315) 568-7477 E-Mail: Warranty.Service@itt.com AO-Ashland Operations Phone (570) 875-6176 Fax: (570) 875-1136 E-Mail Jimmie.Wolfgang@itt.com VPO-Vertical Product Operations Phone (562) 949-2113 Ext. 4155 Fax (562) 695-8523 E-Mail: George.Austin@itt.com

Section 1

Sales Contact: Sales Location: Submitted By: End User: City, State, Zip: Serial #: P. O. # Part #:
Actual Operating Condition *Flow:

Phone #:

Fax: Email: renzo.sanchez@itt.com Date: Or Factory #:

Model#: Part Name:

Size:

( * = Required fields for performance or vibration issues) *Head: *Temp:

*Suction Pressure: *NPSHa: Lubrication: *Date Installed:

Section 2

*Discharge Pressure: *Pumpage: *HP/RPM: *Start up Date:

Non-Conformance: (continue on page 2 as needed)

*Specific Gravity: *Impeller Diam.: Service:

Start/Stop or

Continuous

If this claim is related to a project where a prior claim has been submitted, please provide Claim #

Section 3

Preliminary Field Investigation:

(continue on page 2 as needed)

Section 4

Remedial Action and Proposed Solutions:

(continue on page 2 as needed)

Section 5
Qty Part number

(Please check one) Parts Used or Required

Description Cost

Cost Estimate
Extended Cost

or Invoice Labor / Travel / Total 0 0 0 0

Hours O/T Hours Travel Miles Misc. Expenses @ Rate = @ Rate = @ Rate = 0 0 0

Total

Total Labor Freight Cost Total Cost

CLAIM # :

0 0 0

TO BE COMPLETED BY WARRANTY SERVICES:

WARRANTY SERVICE CONTACT :

Form IBG075 9/18/07 Reference: IBG410, IBG955 1 of 2

WARRANTY EVALUATION REQUEST

Section 2 Non-Conformance:

Section 3

Preliminary Field Investigation:

Section 4

Remedial Action and Proposed Solutions:

Form IBG075

9/18/07

Reference: IBG410, IBG955

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