Forms > Industrial Wastewater Sample Request Form

Company Name

Contact Name (First/Last)

First: Last:

Street Address

City, State, Zip

City: State: Zip/Postcode: Country:

Phone / Fax

Phone: Fax:

Project Name

Project Location

Please provide as much data as possible

	Influent Levels		Effluent Levels
	Avg	Range	Avg	Range	Permit
Flow in Gallons
Temperature
pH
Dissolved Oxygen (mg/L)
BOD - Biological Oxygen Demand (mg/L)
COD - Chemical Oxygen Demand (mg/L)
TSS - Total Suspended Solids (mg/L)
FOG - Fat, Oil & Grease (mg/L)
TPH - Total Petroleum Hydrocarbons (mg/L)
Chrome (Cr)
Copper (Cu)
Zink (Zn)
Lead (Pb)
Flexographic Ink
Other
Other

Please provide a description of the current system and operating conditions:

Please provide background description of the problem