CONVEYOR BELT FIELD SERVICES QUESTIONNAIRE

CONVEYOR BELT FIELD SERVICES QUESTIONNAIRE
Customer*
Today's Date*

MonthDayYear
Date
Site*
Service Date*

MonthDayYear
Date
Time*
Contact*
Phone*
Email*
Address*
City, State & Zip Code*
SERVICES REQUESTED
Remove old belt:*

YESNO
String new belt:*

YESNO
Rewind old belt:*

YESNO
Mechanical splice:*

YESNO
Cold vulcanized splice:*

YESNO
Hot vulcanized splice:*

YESNO
Vulcanized patch:*

YESNO
Patch/repair:*

YESNO
Dutchman:*

YESNO
BELT & CONVEYOR SPECIFICATIONS
Belt manufacturer:*
Belt specification:*
Covers (top & bottom):*
Cover compound:*
Width:*
Length:*
Belt age:*
Belt condition:*
Conveyor Type (overland, shuttle, tripper, etc):*
Is conveyor on grade & level?*

YESNO
If not, please explain (including tail, mid-section and head elevations):*
Take-up style (screw, gravity, etc):*
Take-up travel:*
Splice materials to be supplied by:*

YESNO
FIELD CONDITIONS
Location splice to be performed (tail, GTU, head, etc)*
Clean, safe, dry area for splicing?*

YESNO
Lighting adequate?*

YESNO
Equipment to access splice area, if required, available and provided by customer?*

YESNO
Lifting equipment available and to be provided by customer for:
1) Staging ACT splice equipment (rewind and letoff stands, vulcanizer, etc)?*

YESNO
2) Hoisting and securing GTU, if applicable?*

YESNO
Cooling water available within 50 ft of splice area?*

YESNO
Compressed air available within 50 ft of splice area?*

YESNO
Electric power available (single phase/220V and 110V) within 50 ft of splice area?*

YESNO
AUXILIARY SERVICES & EQUIPMENT
Typically ACT requires that all mechanical conveyor components such as belt cleaners, skirting, guarding, etc. be positioned or removed in order to allow us to proceed with our scope of work. This also includes adjusting and securing the conveyor take-up system based on customer requirements for travel. If needed, ACT is able to work as independently as possible on site. If additional equipment or services are required please identify these below:
Portable generator required:*

YESNO
Assistance required for positioning take up?*

YESNO
Air compressor required:*

YESNO
Assistance required for removal of conv. components:*

YESNO
Misc*
Assistance required for tracking of belt:*

YESNO
* For standard hot vulcanized splice services ACT will normally furnish a trained and certified belt technician and helper, largest vulcanizer possible, proper splice materials, necessary hand tools, belt clamps, come-a-longs, portable strippers, a plywood vulcanizing board and proper safety equipment. Belt crews are MSHA Part 46/48 trained and ACT participatesin a variety of customer specified Safety Compliance programs.
Should be Empty:

CONVEYOR BELT FIELD SERVICES QUESTIONNAIRE

SERVICES REQUESTED

BELT & CONVEYOR SPECIFICATIONS

FIELD CONDITIONS

AUXILIARY SERVICES & EQUIPMENT