NAME:

ORGANIZATION / CITY (NAME):

ADDRESS:

CITY:

STATE:

ZIP:

PHONE:

FAX:

E-MAIL ADDRESS:

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WATER QUALITY
(Fill in all the information below to the best of your ability)
Parameter
Raw Supply
Finished Water
(point of entry)
Finished Water
(distribution)
pH, units
Total Hardness, mg / l as CaCO3
Iron, mg / l
Manganese, mg / l
Zinc, mg / l
Copper, mg / l
90th Percentile, mg / l
Lead, ug / l
90th Percentile, ug / l
Other divalent metals, ug / l
WATER SOURCE
(If more than five, please fill out in details section)
Source
one
two
three
four
five

Well(s) names / #
Do they mix in distribution? Yes No
Well(s) output, gpm
Pressure, psi
Total daily flow, gpd


Surface names / #
Do they mix in distribution? Yes No
Daily flow, gph
Total daily flow, gpd
Please detail present treatment process currently being used for each water source.

FILTRATION
Yes (If yes, type)
No
DISINFECTION
Yes (If yes, type)
No
CHEMICALS CURRENTLY IN USE
CURRENT CORROSION CONTROL TREATMENT
No Treatment
Corrosion Inhibitor
Phosphate
Silicate
Other
Brand Name
Product # or Name
Present Treatment Rate (As Total Product)
Is corrosion inhibitor effective? By what standards has effectiveness been measured? Please provide details.

pH adjustment
Sodium Hydroxide lbs. / MGD lbs. / day
Potassium Hydroxide lbs. / MGD lbs. / day
Sodium Carbonate lbs. / MGD lbs. / day
Lime lbs. / MGD lbs. / day

        

 

 

 

 

 

 

 
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