Title:  Mr Mrs Miss Ms [other]

Name:  

Telephone: 

email: 

Company name:

Address (Post code only at this stage if you prefer):
    

Address of proposed Power Flush (if different from above)
    

System Details:

Boiler Output (approx Kw): Age of system:

Number of Radiators (approx.):

Number of Coils (approx):

Is there an automatic top-up unit? Yes No Is a Single Phase supply available? Yes No

Size of pipework on the boiler header:

General Information

Number of floors:   Is parking available? Yes No

Is a Method Statement required? Yes No Not Sure

Are there any Health and Safety Issues? No Yes Not sure Any Asbestos issues? No Yes Not sure

Is there a mains water supply? Yes No Is there a drain? Yes No

Briefly, why are you looking at having a power flush?