* denotes a required field.
Contact Information
	Company Name
	*Contact Name/Title
	*Address
	*City, State & Zip
	*E-Mail Address
	*Phone Number
	FAX Number
Information Requested
	For Immediate Use	0-6 Months
	For Future Reference	1 Year 2 Year 3 Year
	Other
Project Requirements
	Build	New Plant
	Lease	Warehouse/Distribution Facility
	Retail	Would Consider Build or Lease
	Office Project	Other:
Site Availability
	Minimum Site Size
	Maximum Site Size
Existing Facilities
	Minimum Building Size
	Maximum Building Size
Utility Needs
	Water Requirements
	Number of gallons/day (gpd)
	Peak flow (gallons per minute)
	Sewer Requirements
	Number of gallons/day (gpd)
	Peak flow (gallons per minute)
	Discharge Content (ppm or mg/l):
	Biochemical Oxygen Demand (B.O.D)
	Total Suspended Solids (T.S.S)
	Chemical Oxygen Demand (C.O.D)
	pH
	Temperature: Farenheight Celsius
	Electricity Requirements
	Total kWH hours per month
	Peak kW Demand:
	Are there any unusual fluctuations in load?
	Natural Gas Requirements
	Volume MCF/day (million cubic fee/day)
	Pressure Requirements (pounds/square inch)
	Transportation Requirements
	Please rank the service required, and indicate preferred distance from the following:
	Rank Priority Preferred Minutes Maximum Minutes Rail Service High Moderate Low Freeway Access High Moderate Low Commercial Airport High Moderate Low Marine Container Facility High Moderate Low
	Total Project Investment
	Projected Project Employment Levels