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    Company Name

    Contact Name


    Town & State




    Site Name

    Treatment Process Units (Check all that apply)
    Oil/Water SeparatorAir StripperActivated Carbon (Liquid Phase)UV OxidationFiltrationOther

    Metals Removal (Please Specify)

    Site Details

    Please provide as much information as is available. The success of our deposit control technology is dependent upon the accuracy of our deposit characterization.

    General System and Water Quality Data:

    System Flow Rate

    Total Iron

    Total Hardness


    Water Temperature

    Dissolved Iron

    Total Alkalinity

    TDS or Conductivity

    Discharge to (Check One)
    POTWSurface WaterGroundwaterDrinking Water

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

    Observations of Deposit: If you or your staff have observed deposits occurring at this site, circle any terms that might describe the deposit itself.
    hard scalegranular or flaky, but loosesoft, fine and mud likeslimyredorangeblackwhitetanpinkopaque

    Additional Comments