Wufoo

City Water Recommendation

Thank you for considering PuriTec for your water treatment needs. Please answer the following questions as best you can. If you have any questions call us toll free at 1-888-491-4100.

All information is kept confidential and is never shared.

Water Type: *
Municipal/City Water with Chlorine Municipal/City Water with Chloramines Not sure
Are you concerned about hardness in your water? (i.e. white scaling on pipes, fixtures and appliances.)
Yes No Not Sure
If you know your water's hardness level, enter it here: (Please indicate if gpg, mg/l or ppm.)
Please indicate any concerns you have about your water: *
Taste Odor (i.e. chorine smell or other) None Other
Please indicate any contaminant concerns you have about your water:
Organic Contaminants Heavy Metals (such as lead) Sediment Flouride Pharmaceuticals Other
How many bathrooms are in your home? *
Total number of people living in your home: *
Please add any additional information which may be helpful or any specific concerns you have.
Name * First Last
Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Phone Number * ### - ### - ####
Email *
Do Not Fill This Out

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