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Please complete the following form and submit with your request for system quotation, or download and complete the pdf copy and fax it to Pure Aqua, Inc. at (714) 432-9898.

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CONTACT INFORMATION
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* Contact Name
* Company Name
Address
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* Country Name
Phone Number
* E-Mail
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Product Information  
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Inquiry details/requirements/comments:

Attach your request for quote / Specifications / Water analysis file, or drawing if available.

Other
Water Delivery Distribution Application Required
Equipment
Feed Water Source:
Well
Municipal/Tap
Surface (River/Lake)
Seawater
 Residential(up to 200 gal/day)
Commercial(200-10,000
    gal/day)
Industrial (above 10,000
    gal/day)
If you know your specific requirements, please specify: 		Filtration
Softeners
Reverse Osmosis
Ultraviolet
DI / EDI
Ozone
Other
Product Water Repressurization Needed? Yes No
Required System Capacity  
Available Power

FEED WATER ANALYSIS INFORMATION
Temperature Degree F   Degree C
  High
  Low
pH
TDS
Suspended Solids
Turbidity
Conductivity
Color
Total Hardness

**** IMPORTANT NOTE: Please indicate if ion is reported in ppm, mg/l, CaCO3, or mEq/L

WATER ANALYSIS - Ionic - Should Be a Balanced Analysis
Ca++ CO3--
Mg++ HCO3-
Na+ SO4--
K+ Cl-
NH4++ NO3-
Sr++ F-
Ba++ SiO2
Fe++ Other
Mn++ Other
Other Other
Other Other
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Water Treatment & Reverse Osmosis Systems - WQA Member
2230 South Huron Drive,
Santa Ana, CA 92704 USA
Phone: +1-714-432-9996
Fax: +1-714-432-9898
sales@pure-aqua.com www.pure-aqua.com