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Address:	5925 Monkland Ave. Suite 204,
	Montreal, Quebec, H4A 1G7 Canada
Telephone:	514.667.2095

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Cleaning Application Questionnaire

Thank you for your interest in safely cleaning planet earth.
If you are interested in having one of our representatives contact you regarding a specific problem, please submit the form below and someone will respond within 24 hours.

Completed by:
Name:		Date:
Email:		Telephone:

Company Name:

Address:

City / Province:

Postal Code

What do you want to clean?

What type of surface(s)?

	Metal (ferrous or non-ferrous)
	Plastic
	Rubber
	Concrete
	Vinyl

Other:

What type of soil(s)?

Petroleum lubricants
Dirt / grime
Soot
Proteins / sugars

Other:

How do you clean now?

Dwell time

Agitation

Temperature

Concentration

What type of equipment?

Parts washer
Ultra sonic
Pressure washer
Sprayer
Vapor degreaser
Hand application

Other:

Current cleaners & solvents?

Means of waste disposal?

Oil / water separator
Contracted disposal
Combustion system

Why would you consider a change?

Performance
Health & safety
Environmental impact
Customer service
Cost
Government regulations

Other:

Other Comments:

5925 Monkland Ave. Suite 204, Montreal, Quebec, Canada H4A 1G7

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