Your Name:  * Company Name:  * Address:  * City/State/Zip:  * Phone  * Fax: Email Address: Description Of Operation And Waste Water Source: Flow Rates - Average GPM: Flow Rates - Average GPD: FLow Rates - Max GPD: Water Tempertature: Primary Contaminates: Current Disposition Of Water: Describe Any Existing Treatment/s: Any Water Storage Tanks YesNo If Yes Indicate Type: Above GroundBelow GroundNo Water Storage Tanks Current Water Costs: Sewer Handling Costs: Describe Compliance Problems If Applicable: Water Quality/Standards Desired: Treat For Discharge? YesNo Reclaim For Reuse? YesNo Other Customer Requirements/Comments: Do not enter anything in this field:

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