Name
Mr.
Ms
Mrs.
Miss
Dr.
First name:
Last name: (Required)
Address
Title: Organization:
Street address:
Street address:
City: State or Prov: Postal/ZIP code:
Country:
Phone: Fax:
E-mail address: (Required)
Liquid to be Sampled
Raw Sewage Plant Effluent Pulp/Paper Mill Effluent
Sea Water Fresh Water
Other (Describe)
pH range: from to. Average pH
Liquid depth at sampling point: inches
Liquid Temperature: Minimum°F, Maximum°F
Suspended Solids Parts Per Million: Average Maximum
Type of Solids:
Stringy Granular Chips Solids Float
Heavier than Water? Yes No
Any other description of Solids:
Name any predominant chemicals in liquid to be sampled:
Composite Sampler Installation
Pre-Set Sampling Cycle Flow Proportional*
* Flow Proportional Samplers operate from pulse signals received from customer's flow recording instrumentation.
Sampling Interval Minutes
Daily volume of sample required: Litres/24 hours.
Is power available? Yes No
Volts: Phase: Cycles:
Is compressed air available at the sampling location? Yes No
P.S.I.G.:
Please include any other data which might be helpful in making a recommendation (height and
distance of sample travel, etc.) here:
When you are finished
Be sure to double check that all information is correct
or
