Customer Name:
Company:
Street Address:

City:				State/Province:
Zip/Postal Code:

Telephone:		Fax:
E-mail Address:

My need is immediate	Yes	No
Please have a representative call me	Yes	No

To improve our quality of service on this request, please provide
the following information:

What contaminants are in the waste water?
Organic compounds < 1%	Organic compounds > 1%	Toxic Metals
Salts < 1%	Salts > 1%	Priority Pollutants
What are the sources of the waste water?
Process generated	Rinse waters	Remediation
Contaminated stormwater	Cooling tower blowdown	Other
How is the waste water currently treated?
Biological Treatment	Chemical Oxidation	Membrane Separation
Evaporation	Oil/water Separation	Chemical Precipitation
Activated Carbon	Incineration	Other

 

What is the volume of the waste water?
less than 1 gpm	>1 gpm to 10 gpm
>10 gpm to 100gpm	>100 gpm to 4000 gpm

 

Is the waste water shipped off-site for treatment?	Yes	No
Is reuse/recycling of the clean recovered water of interest?	Yes	No

Please provide other information that may be helpful to our
 Technical Representatives.

  or