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Company Name

Contact Name

Address

Town & State

Phone

Fax

Email

Site Name

Treatment Process (Check all that apply)

Oil/Water

Air Stripper

Activated Carbon (Liquid Phase)

UV Oxidation

Filtration

Other

Metals Removal (Please Specify)

System Flow Rate

Total Iron

Total Hardness

pH

Water Temperature

Dissolved Iron

Total Alkalinity

TDS or Conductivity

Discharge to (Check One)

POTW

Surface Water

Groundwater

Drinking Water

Microbiological Data: If you suspect microbiological growth, and have done any testing, please describe type of testing and results.

Additional Comments