* First Name:

* Last Name:

Company Name:

Title/Position:

* Address 1:

Address 2:

* City:

* State:

* Zip:

Country:

* Phone:

* FAX:

* E-Mail Address:

Location of Planned Installation:

Treated Water Requirements:

Volume Required Per Day:

To be used in
hours per day.

Ultimate use of treated water:

Quality of water required:

Facility - describe existing facility and any problems with facility:

Space for New Equipment:

Length:

Width:

Height:

Location:

Power (Volts):

Max. Amps:

Phase:

Cycles:

Feed to Proposed Treatment Facility:

Seawater

Municipal

Well

Surface

Blend

Water

Other:

Feedwater Temperatures (units):

Average:

Highest:

Lowest:

Feedwater Pressure:

Lowest @ full flow:

Highest @ 0 flow:

Feed Analysis - complete table and include all items requested in PPM as ion:

Calcium (Ca):

Bicarbonate (HCO3):

Conductivity:

Magnesium (Mg):

Sulfate (SO4):

Total Dissolved Solids (ppm):

Sodium (Na):

Chloride (CI):

BOD/COD:

Manganese (Mn):

Nitrate (NO3):

Suspended Solids:

Potassium (K):

Silica (SiO2):

Carbonate (CO3):

Iron (Fe):

Hardness (GPG):

pH:

Chloride:

Turbidity:

Color: