From:____________________ Phone:________________________ Fax: _____________________ ____________________ Belt Information ____________________ Length: __________ Width: ____________ OAG: ____________ ____________________ Plies: ____________ Covers: _______________________________ Fabric: __________ Tension Rating: _________________________ Material Conveyed: _______________________ Belt Rubber Compound: _________________ Chemical Breakdown: _________ % _________ % _________ % _________% ( in % by volume ) B A1 A2 C D E F G Round U V Grooves A. Width of Indent A1 ____________ A2 _____________ B. Length of Groove _________________________________ C. Grooves, Center to Center _________________________________ D. Width of Groove _________________________________ E. Width of Rib _________________________________ F. Depth of Groove _________________________________ G. Shape of Groove Round  U  V  Perforations Holes_____ Size ______ Slots______ Size ______ Perforations, Center to Center _______  Double Holes  Through  Single Holes Rib  Single Slots  Through  Double Slots Groove Standard Holes  Sealed Holes  Fabric-Free Holes  B C1 C2 Bottom Guides/Fabric-Free Zones Skirts Molded Edges  Standard Edges  A. Fabric-Free Zone on Edges, Width: ______________ B. Fabric-Free Zone around Holes, Width: ___________ C. Bottom Guides: C1 __________ C2 __________ All sales are subject to Beltersvice’s standard terms of sale contained in its invoices, copies of which will be provided upon request. Your order will be deemed an acceptance of those terms. Flange Skirt  Cleat Skirt  Wedge Skirt  B H H1 H2 B None  W T Flap  1“  Skirt Height: 1-1/2”  Rubber 2“  Compound: _____________ H. Height: ______________ B. Base Width:__________ Rubber Compound: _____________ Height: H1 ______ H2 ______ B. Base Width: ____________ Rubber Compound: _______________ T. Thickness: ______________ W. Flap Width: ____________ 4143 Rider Trail North • St. Louis, MO 63045 Phone: (314) 344-8500 • Toll Free: (800) 727-2358 • Fax: (314) 344-8511 www.beltservice.com • Email: sales@beltservice.com