Company Name:

Contact:

Address:

City:

State or Province:

ZIP or Postal Code:

Country:

Telephone:

Fax:

E-mail:

Type Water to be Treated:

System ID:

Main System Flow Rate:
Mean      Min      Max        Please choose belowGPMGPD

Does Flow Rate Fluctuate?       Please choose belowYesNo     If Yes, what is the range? (GPM)

Main System Water Pressure: Mean      Min      Max  PSIG

Does Pressure Fluctuate?       Please choose belowYesNo

Desired Chlorine Residual: PPM

Chlorine Demand: PPM

Source Water Supply to Chlorinator System: Mean      Min      Max  GPM

Is the line always full?       Please choose belowYesNo

Desired Water Flow Thru Chlorinator: GPM

Pressure of Water Supply to Chlorinator System: Mean      Min      Max  PSIG

Chlorinator System Discharge Pressure: Mean      Min      Max  PSIG

Duty cycle:      Please choose belowContinuous Interrupted

Hrs/Day Available Electrical Supply: Volts      Amps     Phase

How Will the Chlorinator System be Controlled?      Please choose belowManually Automatically

Source Water Characteristics: pH      Total Alkalinity      Calcium Hardness      Temperature, ^oF

Person Certifying Data:

• Patented Tablet Feeder (NSF STD 61 Certified)
• Integrated, Level Controlled Solution Tank Adjustable Flow Control Valve
• Chlorinator Flow Meter
• Efficient Centrifugal Solution Pump On/Off Control Switch
• Waterproof Electrical Junction Box NEMA 4 Rated
• Corrosion Resistant Schedule 80 Piping
• Reverse Flow Check Valves
• Total Solution Output Control Valve

Scale Inhibitor Option

Flow Proportional Control (Flow Pacing)

Inlet Flow Meter

Low Inlet Pressure Boost Pump

ORP or Residual Chlorine Controlled

Start Delay Timer

Custom Inlet Outlet Fittings

Inlet Supply Line Pressure Regulator with Pressure Gauge

Complete SCADA System Performance Tie-In

Flush Manifold Kit

Inbound Filter

System Output Meter and Pressure Gauge

Electronic w/4-20 mA Output

Visual Rotometer

Low Tablet Signal Alarm