LSP Industries Lubricant Request Form

	* Required Fields Please answer the following questions. Questions that do not apply may be left blank:
Customer Name:*		Company:*
Address:*		Address2:
City:*		State:*
Zip:*		Country:
Phone:*		Fax:
E-mail:*		Distributor Contact Person:
Type of Machine:	A. Lathe Automatic Screw Machine CNC Manual (ie. Engine)	B. Milling Machine CNC Manual (ie. Bridgeport) C. Other
Type of Tooling: (Select One or More)	A. High Speed Steel B. Carbide C. Coated (Describe ) D. Other
Type of Material: (Select One or More)	A. Carbon Steel-	Type
	B. Stainless Steel -	Type
	C. Aluminum-	Type
	D. Brass-	Type
	E. Copper-	Type
	F. Magnesium-	Type
	G. High Alloys -	Type
	H. Cast Iron -	Type
	I. Other -	Type
Operation: (Select One or More)	A. Turning B. Milling C. Drilling D. Grinding E. Tapping F. Sawing G. Broaching H. Other
Subsequent Operations:	Existing Operations A. Cleaning Alkaline Wash Acid Wash Water Wash Solvent Wash Vapor Degrease B. Coating Plating Phosphate Paint Rust Preventative C. Heat Treated or Annealed After Cleaning Without Cleaning D. Welded After Cleaning Without Cleaning E. Stored for length of time.	Desired Operations A. Cleaning Alkaline Wash Acid Wash Water Wash Solvent Wash Vapor Degrease B. Coating Plating Phosphate Paint Rust Preventative C. Heat Treated or Annealed After Cleaning Without Cleaning D. Welded After Cleaning Without Cleaning E. Stored for length of time.
Lubricant:	A. Existing Type of Lubricant: Straight Oil Water Soluble Oil Synthetic Semi-Synthetic Vegetable Oil Other	B. Desired Type of Lubricant: Straight Oil Water Soluble Oil Synthetic Semi-Synthetic Vegetable Oil Other
Method of Applying Lubricant:	Existing Method: Drip Flood Normal High-Pressure Through Spindle Mist Other	Desired Method: Drip Flood Normal High-Pressure Through Spindle Mist Other
Method of Monitoring Lubricant:	Existing Method: None Concentration pH Solids Content Tramp Oil Content Water Content Bacteria/Fungi/Yeast Rust Tests Other	Desired Method: None Concentration pH Solids Content Tramp Oil Content Water Content Bacteria/Fungi/Yeast Rust Tests Other
Method of Maintaining Lubricant:	None Bactericide/Fungicide Treatment Antifoam Skimming Decantation Filtration Other
Special Considerations:	Chip Conveyor Inaccessible Reservoir Centralized System Gallons Excessive Tramp Oil
Reason(s) for Previous Lubricant Failure:	Rancidity Dermatitis Price $ Per Gallon Availability (sump life= ) Transportation cost Rust Protection Tool Life Disposal Cost
My Primary Customer Concern Is:

2511 20th St • Rockford, IL 61104 • 815-226-8090 • Fax 815-226-9250 • Email Sales@Lspind.com