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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