Company *

Address

Street Address *

City *

State *

Country

Postal code *

Phone *

Contact *

Pump Year *

Pump Make & Model *

Pump S/N *

Boom S/N *

Truck Year *

Truck Make *

Truck Model *

Proportional Boom *

Yards Thru Pumping Cyl. *

PTO Hours *

V.I.N *

Truck Hours *

Odometer *

Hub Miles *

Date of Last Certified Boom Inspection *

Last Certified Boom Inspection Report *

Attach Last Certified Boom Inspection Report

Date of Last Certified DOT Inspection *

Last Certified DOT Inspection Report *

Attach Last Certified DOT Inspection Report

*These reports must be current and completed by CERTIFIED BOOM INSPECTOR and CERTIFIED GOVERNMENT DOT INSPECTOR for trade value consideration.

Date of HYD.Oil and Filters Last Changed *

855 E 68th ave. Denver, CO 80229 - www.westernmixer.com - Phone: 303-426-0006 - "Office use"- Western Holdings LTD

General Operation – Pump & Boom Description *

General Operation – Pump & Boom *

Comments for General Operation – Pump & Boom

General Operation – Truck Description *

General Operation – Truck *

Comments for General Operation – Truck

Boom (Visible Damage) Description *

Boom (Visible Damage) *

Comments Boom (Visible Damage) *

Pipeline – Age: Description *

Pipeline – Age: *

Comments for Pipeline – Age:

Rock Type (M, E, Or B) Description *

Rock Type (M, E, Or B) *

Wear Parts – Type: Std or Carbide Description *

Wear Parts – Type: Std or Carbide *

Comments Wear Parts – Type: Std or Carbide

Differential Rods Description *

Differential Rods *

Comments for Differential Rods

Hopper Area Description *

Hopper Area *

Comments for Hopper Area

Fenders Description *

Fenders *

Comments for Fenders

Steps Description *

Steps *

Comments for Steps

Bumper Description *

Bumper *

Comments for Bumper

Tires | All Matching Description *

Tires | All Matching *

Comments for Tires | All Matching

Interior (Seats, Headliner, Floor Mats, Etc.) Decription *

Interior (Seats, Headliner, Floor Mats, Etc.) *

Comments for Interior (Seats, Headliner, Floor Mats, Etc.)

Windows Description *

Windows *

Comments for Windows

Air Conditioning Working Description *

Air Conditioning Working *

Comments for Air Conditioning working

855 E 68th ave. Denver, CO 80229 - www.westernmixer.com - Phone: 303-426-0006 - "Office use"- Western Holdings LTD

OTHERS

ITEMS TO BE INCLUDED WITH UNIT

Type of Radio Remote Box *

Radio Remote Box (Type: ____________) *

Cable Remote *

Remote Cord *

Remote Reel 100’ *

Wood Pads *

Tool Box *

Tip Hose *

Water Hose *

Clean-Out Ball *

855 E 68th ave. Denver, CO 80229 - www.westernmixer.com - Phone: 303-426-0006 - "Office use"- Western Holdings LTD

Additional Comments

Photos: Include all 4 sides; inside cab (driver & passenger side), inside hopper; inside water box; inside sideboard tool boxes including radio & cable remote; & any others. (File Format – JPG File preferable)

Upload Folder of Image *

Completed By *

Date of Evaluation *

Please complete this form and email it along with required photos & documents to karston Brewer | e-mail: [email protected]

For Western Mixer Office Use Only

Estimated Date For Trade to be Delivered to Western Mixer *

855 E 68th ave. Denver, CO 80229 - www.westernmixer.com - Phone: 303-426-0006 - "Office use"- Western Holdings LTD