Go-Green Information Request (red fields required for response)

   First Name:    Last Name:

   Company Name:

   Address:

    City:

   Province :    State :

    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?

How many people maximum will be using the system on a regular basis?

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: