First Name:    Last Name:

   Company Name:

   Address:

    City:

   Province : British Columbia Alberta Saskatchewan Manitoba Ontario Quebec Nova Scotia PEI New Brunswick Newfoundland Inuvik    State : Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

    Country:    Zip Code/Postal Code:

    Phone:     Fax:    

    Email:

   I am a: Homeowner Engineer/Architect Contractor/Developer Other

   Where did you learn about Go-Green?
Referral Yellow Pages   Search Engine        Other  

Where do you intend to install the system?
Residential house Trailer    Office    Factory    Houseboat     Marina    Boat
Subdivision    Other

City or Town of Installation?

Will you be applying water conservation practices? Yes No

What is your reason for a new system?
Repair of current failed system Remodel New Construction Change in government regulations

The overall lot size (where applicable)

There is an existing permit for wastewater disposal Yes No

The intended method for handling the effluent (wastewater outflow) is
Dispersal field River Lake Ocean Other

There is an existing dispersal field (where applicable) ? Yes No

A percolation test and soil analysis test has been done? No Yes     Test results

Electrical Power is available at the intended installation location? Yes No Solar

Special chemicals to process (industrial installations only)

Will there be a cafeteria or restaurant using the system No Yes       Patrons per day

Area for installing unit(boat installations only, specify height,width,length)

Will you require ultraviolet treatment (for example, if effluent to be used for irrigation)? No Yes Don't Know

Will you require denitrification to remove all nitrates(not normally needed) No Yes Don't Know

Would you like Go Green personnel to handle installation (BC, Alberta or Washington only) Yes No

Would you like Go Green personnel to handle all aspects of project (BC, Alberta or Washington only) Yes No

When will your project start? Immediately 2-3 months 4-5 months 6+ months

Preferred method of responding to this request Email Fax Phone Letter

    Additional Comments: