Customer

Customer Contact Name

Tower Site Name

Tower Site Location

Customer Address Line 1

Customer Address Line 2

Customer City

Customer State

Customer Zip Code

Country

Customer Telephone Number

Customer E-mail

Customer Confirm E-mail

Sandown Wireless assumes normal site & access for our delivery & construction trucks.

This Tower is for: Material Only Material and Installation by Sandown Wireless / Radian/ROHN

Type of Tower: Guyed Bracketed Self Supporting Roof Mounted

If Self Supporting: Triangular Pole

Total Tower Height

Base of the Tower will be at: Ground Level Roof at feet above grade.

E.I.A. Operational Requirements: Yes No Other, Explain:

#1 Step Bolts or Ladders: None Yes, Required

Location Of Step Bolts or Ladder:

Inside                    Face                    Standard

Outside                  Corner                Heavy

Step Bolts              Leg                     Other

Safety Device, Anti-Fall System: ROHN-LOC System Other, Explain:

#2 Obstruction Marking and Lighting: None

Aircraft Warning Lights: Yes No By Others, Explain:

If Yes: FAA - or - ICAO

Type: Incandescent Strobe L.E.D. By Others, Explain:

Beacon Plate Required: FAA Strobe Manufacturer

Paint: Factory Applied Sufficient Paint for Field Application

#3 Vertical Waveguide Support:

None             Ladder         Brackets

Conduit         Brackets       Other

Location of Vertical Waveguide Support (If Preference):

Waveguide Bridge: Please provide a sketch and explanation:

#4 Platforms: Not Required Required (Provide elevation and description)

#5 Lightning Protection None

Lightning Rod Required: Yes No      If Yes, quantity:

E.I.A. Grounding: Yes No Special, Explain:

#6 Antenna Information:

VHF/UHF mounts must state type of mount and the length of the side arm, if applicable. Send us a separate sheet if necessary. This information is absolutely necessary for us to be able to quote your tower. We must know your total antenna and feed line load!

If this is a cellular carrier tower, how many carriers is the structure going to support?

For each antenna on the tower (supply a separate sheet if necessary):

FIRST TYPE OF ANTENNA

• (1'st) First Type of Antenna on Tower. Quantity

• Model Number, Manufacturer, Size, Weight & Wind load

• Frequency

• Elevation on tower above ground

• Azimuth if Applicable

• Antenna Mount Required? Yes No Supplied By Others

• If Supplied By Others: Make Model

• Number of Tiebacks

• Ice Shield?Yes No Supplied by Others

• Feed Line size, Manufacturer, Part Number and quantity

SECOND TYPE OF ANTENNA

• (2'nd) Second Type of Antenna on Tower. Quantity

• Model Number, Manufacturer, Size, Weight & Wind load

• Frequency

• Elevation on tower above ground

• Azimuth if Applicable

• Antenna Mount Required? Yes No Supplied By Others

• If Supplied By Others: Make Model

• Number of Tiebacks

• Ice Shield?Yes No Supplied by Others

• Feed Line size, Manufacturer, Part Number and quantity

THIRD TYPE OF ANTENNA

• 3'rd) Third Type of Antenna on Tower. Quantity

• Model Number, Manufacturer, Size, Weight & Wind load

• Frequency

• Elevation on tower above ground

• Azimuth if Applicable

• Antenna Mount Required? Yes No Supplied By Others

• If Supplied By Others: Make Model

• Number of Tiebacks

• Ice Shield?Yes No Supplied by Others

• Feed Line size, Manufacturer, Part Number and quantity

#7 THE FOLLOWING DATA IS REQUIRED FOR SPECIAL FOUNDATION DESIGNS (send separate):

• Allowable bearing capacity

• Boring log showing composition and variation with depth

• Water table depth and variation

• Type of foundation recommended (pile, spread footing, mat etc.)

• Uplift recommendations, pertinent to the type or types of foundations recommended

Consistency of soil:

A. Unconfined compression strength of cohesive soil (clay)

B. Standard penetration - Blows per Foot

C. Rock quality designation for rock

• Allowable passive pressure in pounds per square foot of depth (PSF/FT)

• Backfill considerations

• Factors of safety included in allowable design values

NOTES:

• 1. Before soil boring work begins, the soils engineer should contact Sandown Wireless for tower reactions, preferred boring locations, and any other data the soils engineer may require.

• A detailed soils report, with proper foundation recommendations, will produce the most economical and safe foundation design.

#8 Additional Information, Comments or Special Requirements:

If you have separate data to send with this form attach it to an E-mail and send it separate with this form.

Hit the Submit Form Button when you are ready.

You may also Fax this Form to: 603-887-2117 after you print it out

Sandown Wireless

P.O. Box 564, East Hampstead, NH 03826

Toll Free: 866-379-8437