Buckeye Detection Systems Fixed Detection Systems Application Survey

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1 Buckeye Detection Systems Fixed Detection Systems Application Survey Channel Partner Representative : Company Name: Representative: BDS Representative: Client Contact Information : Company Name: Company Representative: Address: State / Province: Department: Title: City: Zipcode: Country: Application Waiver : Would the customer like to request an application form waiver due to prior experience / success with Buckeye Detection Systems products in an identical application usage. By checking the, you agree that you will assume all responsibility for the application and functionality of the system in this application, as it will not have been reviewed by Buckeye Detection Systems personnel. You further agree that if the system malfunctions for any reason not related to a defective system (in which case Buckeye Detection Systems will of course honor the product warranty), you will reimburse Buckeye Detection Systems for all expenses reasonably incurred by Buckeye Detection Systems to make your systems fully operational. I agree to the foregoing. Initial: Project Information : Project Name: Project Location/ Facility: Project Engineering Group: Priority and Time Frame of Response : Final date of Submitting Proposal: Project Award Announcement : Installation Start : Other: Terms & Conditions : Please attach a copy of the terms conditions and clauses that are related to this project if any. Startup, Commissioning or Training : Do you require startup, commissioning or training service from Buckeye Detection Systems Application Information : New Installation Retrofit of Existing Installation Addition to existing Buckeye Detection Systems, waiver applicable? Power Requirements : What Power is available onsite: 120 VAC 240 VAC 24 VDC 12 VDC Other power requirements / considerations : Page 1

2 Sensor / Transmitter : Combustible / Flammable / Explosive Monitoring : rmal Scale Qty tes: ( * LEL Target / es ) % LEL - Catalytic % LEL - IR * LEL Target identification mandatory for survey approval and processing. Oxygen Monitoring : rmal Scale Qty tes: O2 -Vol % Toxic es Monitoring : rmal Scale Qty tes: Relative notations NH3 CO2 CO CL2 CLO2 H2 HCN HF H2S NO NO2 O2 O3 SO2 Other es Present? (Potential Inhibitors or Interferences) Concentration Range Remarks te any other Inhibitor or Interference Concerns : Flame Detection : Qty UV, UV/IR, IR3 Flame source (Hydrocarbon, Hydrogen, Natural, etc. Page 2

3 Additional Potential Interferences? (i.e. dust, mist, steam traps, fans, EMF, RFI, large electric motors, etc.) If, please explain below Temperature : What is the min / max temperature range of sensor / transmitter location? Min Temp Max Temp F C Relative Humidity : What is the relative humidity range at the sensor location? Min RH % Max RH % Environment : Will the Sensor be located? Indoors Outdoors Special Considerations : Duct Mount Remote Sampling Required Other Sampling Requirement Sensor Remote If any of the above are selected, please explain below Area Classification Requirement at the Sensor Location: Is the area classified as : n Hazardous Area Hazardous Area Wiring / Distances: Existing Wiring New Wiring System Wireless (See Wireless Systems Survey Form) What is the maximum distance that a sensor/transmitter would be mounted from the controller? Wire Gauge / Dia 16 AWG mm 18 AWG -.823mm 16 AWG mm Other If utilizing existing wiring is it: 2 Wire 3 Wire 4 Wire Other Shielded Transmitter Output Requirements: Transmitter Output (Check all that apply) Digital Comm. - Modbus RTU Analog Comm mA Relay Isolation Wireless Other Controller Information: Buckeye Detection Systems Controller Required? If, Total number of inputs If, (Check one) Fire Alarm Panel PLC DCS Other Mfg / Model If PLC / DCS, Is the input from controller or transmitter? Controller Direct from Transmitter Page 4

4 Is there a need for additional display in a location other than the controller? (Control room, security office, lobby, or the entry point of the detection area) If, Please describe requirement: BDS Controller Power Requirements : What Power is available onsite: 120 VAC 240 VAC 24 VDC 12 VDC Other power requirements / considerations : BDS Controller Features : NEMA 4X 19 Rack Mount Panel Mount NEMA 7 Does the controller require specific outputs RS485 - Modbus RTU Analog Out / 4-20mA Relay Ethernet Wireless Other If Other, Please describe below: BDS Controller Relay Outputs : Does the Controller require Relay Outputs: If, Common Discrete Voting / Zoning Logic Required? Please provide relay details, ratings, levels, etc below: BDS Controller Environment : What is the min / max temperature range of Controller location? Min Temp Max Temp F C Will the Controller be located? Indoors Outdoors Area Classification Requirement at the Controller Location: Is the area classified as : n Hazardous Area Hazardous Area Alarm Annunciation : Are there Visual or Audible Alarms Required: Is the area classified as : n Hazardous Area Hazardous Area Specify number of Visual or Audible Devices Required, Device details, (color, loudness, etc.) : Page 5

5 Calibration : Does the installation require calibration gases and accessories? Please provide calibration details below, (calibration gas, concentration, etc.) : Accessories : Does the installation require additional Accessories? If, Please describe below: Battery Backup : Does the system Require Battery Backup? If, Please describe below, (runtime hours upon loss of power, etc.) : Data Logging : Does the System require Data Logging? If, Please describe below: Application Drawing : Is an application drawing / schematic available for review? If possible, drawing should include dimensions of the area, gas sources, hazardous areas with classifications, typical airflow, air intakes, fans walls / barriers, etc. Drawing may be on additional pages as needed or provided as a separate attachment. Please Review, Sign and End-User Name (Please Print) Channel Representative (Please Print) End-User Signature Channel Signature Approved by BDS Applications Engineer (Please Print) Regional Sales Manager The Application Form can be completed and saved as a separate file. Then print, sign, etc. and attach to an The Application Form can be completed and submitted electronically to a Buckeye Detection Systems Sales / Application Engineer. Submit Page 6

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