Virotec

Name of your Company:

Name of Parent Company (if applicable):

Name of Contact:

Postal address:

Phone:

Fax:

Email:

Website URL:

Location of the problem site:

Nature of the problem (check all boxes that apply):

Surface Water - Ponded

Surface Water - Flowing (show minimum, maximum and average flow rates)

Groundwater

Soil/Sediment

Sulphidic mine wastes

Industrial waste - solids/liquids

Sewage - solids/liquids

Potable water

Other (brief name)

Brief description of the problem:

Components of concern (check boxes that apply):

Metals

Acid

Phosphate

Other (please specify)

Your company's objectives/requirements regarding the problem:

Please list requirements to be met to satisfy any regulatory authorities (if applicable):

Please state the level of urgency regarding the problem (e.g. immediate and critical urgency, some urgency, medium term urgency, not urgent - preventative measure):

Please provide the following available data (fill in data such as number/weight of samples or other units):
List contaminants ... ... ... value ... ... ... ..units

Contaminant	Water quality targets	Other compositional data

Water or solids composition:

Volume or mass to be treated:

Treatment timetable:

Please list any risk factors to be considered (e.g. flood risk, dam failure, acid scalds, water eutrophication, etc.):

Other comments: