Name
Company
Title
Address
City
State
You prefer:	Fixed Monthly Contract Pay for Chemicals based on usage
You currently receive:	Monthly Service Semi-Monthly Service Weekly Service Other
Your current chemical provider transports chemicals	To Loading Doc To Servicing Site To servicing Site adding to Secondary Containment To Servicing Site, Online Secondary Containment, Disposal from Site
You are concerned with Total Operating Costs Including	(pick all that apply)
	Total Utility Cost for Plant/Facility
	Utility Cost for Individual Systems (ie.boilers, chillers, towers, condensers)
	to service site and puts on line
	to service site, puts on line, and disposes of chemicals
Comments: