Chiller Replacement Questionnaire

Facility Name

Facility Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Site Contact

First Last

Phone

Email

Target Date

Current System Information

System (MRI, CT, etc.)

Brand

Model

Chiller Brand

Serial

Model

Voltage

Have any changes or upgrades been made to the imaging system? If yes, please provide explanation.

Yes
No

Notes

Has the system been relocated or moved from original location? If yes, please provide explanation.

Yes
No

Notes

Will the replacement chiller be installed in the same location as the current chiller? If no, please explain.

Yes
No

Notes

Does the current system include a separation cabinet (LCC, SEP, HEC)?

Yes
No

Notes

Does the existing piping include a city water bypass?

Yes
No

Notes

Is the ambient temperature below 113F (45C)?

Yes
No

Notes

Is the ambient temperature above -13F (-25C)?

Yes
No

Notes

Does this facility require OSHPD pre-certification?

Yes
No

Notes

Where is the current chiller located?

Inside
Outside
Rooftop

Please check if the either of the chiller configurations listed applies to the current chiller.

Water Cooled
Remote Condenser

What is the approximate horizontal distance between the system and the chiller installation? (ft)

What is the approximate vertical distance between the system and the chiller installation? (ft)

Special Considerations

Name of Project Manager

First Last

Company Name

Phone

All Applications

Chiller Replacement

Chiller replacement questionnaire

Current System Information

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