Copper Silver Ionisation Proposal Form

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Request Proposal Form
AquaLyse® Copper Silver Ionisation

In order to properly evaluate your water treatment needs, please fill all applicable fields and click the "Send Information" button in the lower part of this online form.
Thank you!

Company Name:

Your Full Name:

Your Title:

Company Address:

City:

State/Province:

Zip/Postal

Country

E-mail:

Confirm E-mail:

Telephone:

ext:

Mobile or Direct :

Fax:

Information on Your Water System(s), Network(s) or Tank(s)
(Please answer all applicable fields)

Type of Water:

Total water volumes
to be treated

Number of domestic hot water loops:

(if applicable)

Approximate
Domestic Hot Water
usage per day
(M3PD or GPD)

Loop 1

Loop 2

Loop 3

Loop 4

Number of patient beds per Domestic Hot Water loop

Beds/Loop 1

Beds/Loop 2

Beds/Loop 3

Beds/Loop 4

Please describe the location where the water network(s) is (are) located.

Average Water TDS:
(Total Dissolved Solids)

ppm (if available)

Average Water pH:

Calcium Hardness:

ppm (if available)

Average Incoming Domestic Water Temperature:

Additional Information to help us better understand your facility infrastructure and/or water treatment needs:

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