Date Contacted: _____________

Client: ___________________________ Phone:________________________

Address: _______________________ FAX: ___________________________

___________________________________ E-mail:______________________

Contacts: _______________________________________________________

_______________________________________________________

(Name) (Title)

_______________________________________________________

(Name) (Title) 

1. How many people are in your family?

2. How many bathrooms are in your house?

3. Do you eat a lot of bacon, cook with a lot of lard, etc?

4. Do you use a garbage disposal?

5. Do you use a lot of chemicals, either in your toilets or to wash floors with?

Yes No

6. Describe chemicals (example Clorox and Tide in laundry daily, Cascade dishwashing powder twice a day, Lysol to wash bathrooms, etc.)__________________________

_________________________________________________________________

_________________________________________________________________

7. Where does your water come from? City Well Spring

8. When did you first notice problems in your system?

9. Have you used other products to treat this problem? Yes No

10. If yes, please list the products used, and what they claim to contain:

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

11. If you were given a prescription for a weekly application of a liquid product in your kitchen drain and an every-other-month dose to your toilet, would you remember to apply it? Yes No

12. Would you prefer the economy of using a dry concentrate, that must be mixed with water before it is used, or do you prefer a ready-to-use liquid product?

13. Do you prefer automated product applications? Yes No

14. Does you kitchen sink have room under it for a 5 gallon pail and a small metering pump?

Yes No

1. How long ago was your septic system installed?___________________________

2. What is the capacity of your septic system?_______________________________

3. Do you have a single house or are you on a farm? Single building Two buildings Three building Four buildings

4. If more than one building, does the waste from all buildings go to one septic system?

Yes No

5. Do you have access to your "distribution box"? Yes No. (This is a box right AFTER your septic system, leading into the drain field. This would allow you to add some product that will go right to the leach field and not be used up in the septic system on NEW grease.)

6. Do you have a separate system for your laundry wastewater? Yes No

7. If yes, have you had any problems with that system? Yes No

8. Was your drain field ever working properly? Yes No

9. Is the slow draining because you are in a flood plain? Yes No

10. Have you ever had your septic system pumped? Yes No

11. If so, how often? once a year twice a year more often than that

12. If there is a strong odor around the drain field, would you describe it as "sewage-like"? or more like "rotten eggs"?

13. Do you have odors backing up into your sink and drains in the house?Yes No

14. If yes above, "sewage-like" or "rotten eggs".

1.What sort of food is prepared in your facility? health food with little grease lots of high-fat and grease content

2. How big is your drain field?___________________________________________

3. What is your flow rate? __________________________(Gallons per day)

4. How large is the diameter of your pipes? ______________

5. How many people do you serve a day? _______________

6. Do you have room under your sink to install an automatic metering pump and a 5 gallon pail? Yes No

7. Do you have a "grease trap" - separate unit to skim off fats and grease, or does everything go straight to the drain?

8. Does your drain lead to a public waste treatment collection system? Yes No

9. Do you have a septic system? Yes No

10. If no, please fill in NPDES discharge permit parameters (below) and attach the last test results of your effluent water.

11. If yes, how large is the capacity of your septic system? ______________________

12. Do you have access to your "distribution box"? Yes No. (This is a box right AFTER your septic system, leading into the drain field. This would allow you to add some product that will go right to the leach field and not be used up in the septic system on NEW grease.)

13. Has your septic system required pumping? Yes No.

14. If yes, how often? Once a year Twice a Year 3 - 4 times a year Monthly

15. Has the plumber ever said that the design of your system was a problem? Yes No.

16. If yes, is the slope inadequate? Yes No. Is the pipe diameter too small for the waste you are discharging? Yes No. Is the drain field too small for the amount of waste you are discharging? Yes No

17. Is your drain field working slowly? Yes No.

18. Or is the drain field completely plugged? Yes No.

19. Have you experienced odors from the drain lines? Yes No.

20. If yes, "sewage-like" ?Yes No, or "rotten-egg"? Yes No.

21. Would you prefer the economy of using a dry concentrate, that must be mixed with water before it is used?

22. Would you prefer a ready-to-use liquid product?

23. Do you prefer automated product applications? Yes No

24. Does you kitchen sink have room under it for a 5 gallon pail and a small metering pump? Yes No

Please state whether using NPDES limits -OR- target process limits ___________________

pH __________

BOD ___________mg/L lbs./day

COD ___________mg/L lbs./day

TSS ___________mg/L

D. O. ___________mg/L

FOG____________ mg/L

Fecal coliform ___________count/100ml

Ammonia-nitrogen ___________mg/L

Ammonia-nitrate ___________mg/L

Phosphorus ___________mg/L

OTHER ___________ units________