Shipping & Receiving Dept., Ext. 8803, Room L.381

Medical Gases Request Form

Forward completed form to the Shipping Receiving dept.
Prices subject to change without notice.

From: Date:
 Room:
Approved By:
 Department:
 Account #:
Office Use Only
Qty
Product Description
Item Part No.
Size
Contents
Price ea.
Extended.
Barcode No.
Room No.
  In-Stock Gases            
CO2 Medical 8849 K 50 lb $23 $    
CO2 Medical Siphon 8855 K 50 lb $23 $    
  Special Order Gases              
Aerobic Mixture 5% CO2/O2 5706 K 200 cf $111 $    
Air Medical USP 9237 T 310 cf $17.50 $    
Air Zero <1.0 PPM THC 1726 T 220 cf $141 $    
Argon Ultra High Purity 99.999% 2782 T 336 cf $102 $    
CO2 Anaerobic 4346 K 60 lb $51 $    
CO2 Industrial 8895 K 50 lb $16 $    
CO2 Industrial Siphon 8917 K 50 lb $16 $    
Helium HP 99.999% 14354 K 200 cf $78 $    
Helium UHP 99.999% 5202 T 291 cf $109 $    
Helium Zero 99.998% 5PPM THC 5806 T 291 cf $156 $    
Hydrogen Zero 99.995%>0.5PPM  1480 T 258 cf $135 $    
Medical Drug Mixture 5% CO2/O2 2758 K 200 cf $$93.50 $    
Nitrogen HP 99.995% 6479 K 226 cf $191 $    
Nitrogen Medical (E) 7515 E 21 cf $8.50 $    
Nitrogen Medical (K) 7521 K 180 cf $14.50 $    
Nitrogen Medical Liquid Low Pres (180 ltr) 7589 180 4512 cf $75.00 $    
Nitrogen Medical Liquid Low Pres (230 ltr) 12657 230 5850 cf $114 $    
Nitrogen Medical Liquid Low Pres (330 ltr) 23300 300 8200 cf $148 $    
Nitrogen Prepurified 99.998% 7065 T 226 cf $31.00 $    
Nitrogen UHP 99.999% 3110 T 226 cf $144.00 $    
Nitrous Oxide USP (K) 8975 K 56 lb $73.00 $    
Nitrous Oxide USP (E) E 40cft $51.00 $    
Oxygen Industrial Q 7309 Q 80 cf $7.50 $    
Oxygen Medical (E) 7299 E 25 cf $5.00 $    
Oxygen Medical (E) aluminum 7323 E 25 cf $5.00 $    
Oxygen Medical K 7303 K 225 cff $14.00 $    
Propane Instrument 99.5% 4588 F 5 lb $80.00 $    
 
Misc Gases
(list item info below)
              
     
     
  Rental Rates
(per cylinder, per day) *
              
  Medium & Large   H,K,M,Q   $0.16      
  Liquid LG's       $1.33      
Received by: Grand Total:

*Rental rates (fees) and delivery fees will be charged to the appropriate departments via a monthly cost transfer, proportionate to quantities ordered.
**Receiving Department will contact requestor to schedule delivery.