NorFalco LLCSulfuric Acid – First Order Customer Information Form

**Please complete in full**

SECTION 1 – BILL-TO CUSTOMER INFORMATION - SULFURIC ACID

BILL-TO COMPANY NAME:
BILL-TO ADDRESS (Street/PO Box):
City, State, ZIP/Postal:
GST/IRS NUMBER:
LINE OF BUSINESS:
INTENDED END USE OF H2SO4:

CONTACT Information:

PURCHASING CONTACT: / Name:
Tel #: / Fax #:
E-mail:
ACCOUNTS PAYABLE CONTACT: / Name:
Tel #: / Fax #:
E-mail:
ORDER CONTACT: (Person placing orders – If different from Purchasing Contact) / Name:
Tel #: / Fax #:
E-mail:
Where are they located? / Bill-to Address: Ship-to Address: / Ship-to Address:

PAPERWORK Distribution:

C OF A faxed to: / Name: / Fax #:
E-mail:
SHIPMENT NOTIFICATION faxed to: / Name: / Fax #:
E-mail:
MSDS sent to (Bill-to customer above): / Name:
Address:
(If different from above)
E-mail:
Tel # / Fax #:

SECTION 2 – SHIP-TO CUSTOMER INFORMATION - SULFURIC ACID

SHIP-TO COMPANY NAME:
SHIP-TO ADDRESS (Street # & Street Name):
Additional Address Info (dock, plant, etc.):
City, State/Prov, Zip/Postal Code:
IRS NUMBER (MANDATORY for All US Customers):
ANNUAL CONSUMPTION:
INTENDED END USE OF H2SO4:
H2SO4 WILL BE USED FOR "FOOD USE"
U.S. Customers please confirm if acid is intended for "food use", defined by the Oct 10th, 2003 FDA Bio-terrorism Act as "articles used for food or drink for man or other animals, chewing gum, or articles used for components of any such articles". THIS SECTION MUST BE COMPLETED. / Yes: / No:
Newly approved delivery locations are sent a NorFalco Acid Safety video. Which format is preferred: / CD-ROM / VHS
SITE CONTACT (Day Shift): / Name: / Tel #: / Fax #:
E-mail:
(Evening & Weekends): / Name: / Tel #: / Fax #:
Site Technical contact: / Name: / Tel #: / Fax #:

PAPERWORK Distribution:

C OF A faxed to: / Name: / Fax #:
E-mail:
SHIPMENT NOTIFICATION faxed to: / Name: / Fax #:
E-mail:
MSDS sent to (at ship-to customer above): / Name:
Address: (If different from above)
E-mail:
Tel #: / Fax #:
DELIVERY MODE: / Truck: / Rail:
ORDER QUANTITY: / LBS OR KG: / GALLONS:
Is the acid: / Re-Sold: / Consumed Internally:

DIRECT DRUMMING Instructions:

Do you do drumming directly from the transportation container (without an interim tank)? / Yes: / No:
If yes, and you receive via truck, how long is the truck required to be on-site? / Hours
SECTION 3– SHIPMENT INSTRUCTIONS – SULFURIC ACID

TRUCK SHIPMENT Instructions:

Who unloads the truck? / Driver: / Plant Operator:
If Driver, are they alone during unloading: / Yes: / No:
If yes, describe what emergency procedures are in place?
Unloading By: Pump? / Yes: / No: / If Yes, Truck Pump: / Or, Plant Pump:
Air Pressure? / Yes: / No: / If Yes, Truck Air*: / Or, Plant Air:
*Note: If Truck Air is required an additional charge may be incurred.
If unloading by air, what pressure is used? (Maximum of 30 PSI): /

PSI

Axle restrictions: (i.e.) length of truck: / Yes: / No:
If yes, details:
Air hose/line: / Chicago fitting: / 1”Quick connect:
Discharge acid line fitting: / 2"Flanged 4-bolt: / 2"Quick connect:
Other:
Length of Hose: /

FEET

Receiving Hours:
(unloading times for acid deliveries)
Preferred delivery time:
NorFalco's delivery hose policy requires our truckers to supply special high quality sulfuric acid hoses to ensure safe and leak free delivery. Please confirm if this fits with your delivery requirements: / Yes: / No:
If you have any special truck tank type/design requests, please specify here:
Are there site rules applicable to the truck driver? If yes, please specify here:
Do you require a C of A to accompany truck driver? / Yes: / No:
Is there a designated discharge area to be noted on the bill of lading? If yes, please specify here:
ADDITIONAL COMMENTS:

RAIL SHIPMENT Instructions:

Delivering Carrier:
Special Request:
If unloading by air, what pressure is used? (Maximum of 30 PSI) /

PSI

NorFalco LLC

SECTION 4– FIRST ORDER REVIEW – SULFURIC ACID
Have you ever received acid before: Yes: by Rail: ______; Truck ______; Marine/Vessel ______

No:
Storage tank Size: / U.S. Gallons: / Tons:
What is the material of Construction for your Storage Tank?
If it is lined, specify liner material:
Is there a storage tank inspection program in place? / Yes: / No:
How do you verify that the receiving tank has enough space to accept an order?
Is there adequate containment or spill control in place at the unloading and storage areas? / Yes: / No:
Material of Construction at the connection point: / Steel (Carbon or Stainless Steel): / Other (specify):
i) Connection Fitting Material:
ii) Piping Material at Connection Fitting:
Is a working safety shower and eyewash within 50ft. of the connection points? / Yes: / No:
Is the shower Easily accessible and unobstructed? (NorFalco cannot deliver without this in place) / Yes: / No:

GENERAL COMMENTS:

COMPLETED BY / DATE:

SECTION RESERVED FOR NORFALCO LLC

Approved:
Not Approved:
Reason:
Must have Pre Delivery Survey / Yes: / No:
Comments:
Name: / Date:

Revised September 12, 2005

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