Drain & Septic System Evaluation!

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Company Name:
Address:
Distributor:

A. Private Home with Drain Problems How many people are in your family? How many bathrooms are in your house? Do you eat a lot of bacon, cook with a lot of lard, etc.? Yes No Do you use a garbage disposal? Yes No Do you use a lot of chemicals for laundry, dishes, and floors? Yes No What chemicals do you use in toilets and to wash floors? (Brand names, please - such as Chlorox and Tide in laundry, Cascade in dishwasher, Lysol spray cleaner in bathrooms) Where does your water come from? City Well Spring When did you first notice problems in your system? Have you used other products to treat the problem? Yes No If you answered yes above, please list the products used, their purported purpose and any ingredients known: If you were given a prescription for the weekly application of a liquid product in your kitchen drain and an every other month application to your toilet, would you remember to apply it? Yes No Would you prefer the economy of using a dry concentrate, that is best when mixed with warm water, or would you prefer a "ready-to-use" liquid product? Prefer dry Prefer liquid Do you prefer automated product applications? Yes No Does your kitchen sink have room underneath to place a 5 gallon pail and a small automatic metering pump? Yes No If you have a septic system, please fill in section B. ALSO before clicking "submit"

B. Private Home With Septic System Answer all of the questions in part "A." PLUS the questions in this section if you have a septic system. How long ago was your septic system installed? What is the capacity of your septic system? How many buildings are on your property? Single building 2 buildings 3 buildings More If more than one building, does the waste from all buildings go into one septic system? Yes No Do you have access to your "distribution box"? Yes No This is the box right after your septic system, leading into the drain field. This would allow you to add some product directly to the leach field that would not be used up in the septic system on new grease and waste. Do you have a separate system for your laundry wastewater? Yes No If yes, describe any problems with the laundry system: Is your drainfield currently working? Yes No Has your drainfield ever worked properly? Yes No Are you in a flood plain? Yes No Have you ever had your septic system pumped? Yes No If yes, how often? Once a year Twice a year More Less than once a year If there is a strong odor around the drain field, select the smell that is most similar: Like sewage Like rotten eggs Do you have odors backing up into your sink and drains inside the house? Yes No If yes to the above question, what does it smell like? sewage rotten eggs

Restaurant/Hospital/Nursing Home Select which variety of food best describes the food prepared in your facility: Health food with little fat High fat and grease content* * Examples: southern cooking, French cuisine, etc. What is the size of your drainfield? Describe your flow rate, in gallons per day: What is the diameter of your pipes? How many people do you serve per day? Do you have a "grease trap" - separate unit to skim off fats and grease? Have grease trap No grease trap Does your drain lead to a public waste treatment collection system? Yes No If you discharge to a waste treatment authority, please fill in the NPDES effluent limits section at the end of this survey, and e-mail or fax a copy of the results of your last effluent laboratory tests. Do you have a septic system? Yes No HINT: You will not have a septic system if your waste goes to a public system. What is the capacity of your septic system? Do you have access to your "distribution box"? Yes No This is the box right after your septic system, leading into the drain field. This would allow you to add some product directly to the leach field that would not be used up in the septic system on new grease and waste. Has your drainfield ever worked properly? Yes No Are you in a flood plain? Yes No Have you ever had your septic system pumped? Yes No If yes, how often? Once a year Twice a year 3 - 4 times a year Monthly Has your plumber ever told you that the design of your system was inadequate? Yes No If inadequate - is the slope sufficient? Yes No - or - is the pipe diameter too small for the waste you are discharging? Yes No - or -Is the drain field too small or does not percolate properly for the amount of waste you are discharging? Yes No How is your drain field working? Fine Slow Plugged If there is a strong odor around the drain field, select the smell that is most similar: Like sewage Like rotten eggs Do you have odors backing up into your sink and drains inside the building? Yes No If yes to the above question, what does it smell like? sewage rotten eggs Would you prefer the economy of using a dry concentrate, that is best when mixed with warm water, or would you prefer a "ready-to-use" liquid product? Prefer dry Prefer liquid Do you prefer automated product applications? Yes No Does your kitchen sink have room underneath to place a 5 gallon pail and a small automatic metering pump? Yes No

Current Effluent Levels and Limits (NPDES) or Targets

Current pH

NPDES Limit or Target pH

Current BOD mg/L lbs/day

NPDES Limit or Target BOD mg/L lbs/day

Current CODmg/L lbs/day

NPDES Limit or Target CODmg/L lbs/day

Current TSS mg/L

NPDES Limit or Target TSS mg/L

Current D.O. mg/L

NPDES Limit or Target D.O. mg/L

Current FOG mg/L

NPDES Limit or Target FOG mg/L

Current Fecal coliform count/100ml

NPDES Limit or Target Fecal coliform count/100ml

Current Ammonia-nitrogen mg/L

NPDES Limit or Target Ammonia-nitrogen mg/L

Current Ammonia-nitrate mg/L

NPDES Limit or Target Ammonia-nitrate mg/L

Current Phosphorus mg/L

NPDES Limit or Target Phosphorus mg/L

Current Other (state units of measure):

NPDES Limit or Target Other (state units of measure):

We usually add all people who inquire about our products to our newsletter mailing list, which is kept for in-house use. We do not ever sell or trade names of our clients, and rarely contact by e-mail more than once a month. Mailing list: YES NO

for the old "print and fax" version of this form

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