Please provide the following contact information:

            Name 
           Title 
         Company Work Phone 
  Street Address        FAX 
 Address (cont.)     E-mail 
            City   Web-Site 
  State/Province 
 Zip/Postal Code 
         Country 

Application Information: (Please complete as much as possible)

1.  Facility Power Voltage Requirement:

115VAC-1Ø-60 Hz	208VAC-1Ø-60 Hz	230VAC-1Ø-60 Hz
208VAC-3Ø-60 Hz	230VAC-3Ø-60 Hz

 

2.  Wastewater Process Chemical Components To Be Treated:

Test Sample Provided                  Date:
Current Wastewater Effluent pH Level:
Required Treated Effluent/Drain pH Level:

  

Chemical(s) Description	Ratio/Mix	Effluent Status
		Diluted	Concentrated
		Diluted	Concentrated
		Diluted	Concentrated
		Diluted	Concentrated

 

   

3.  Special Requirements / Notes: