Aqueous Cleaner ONLINE

Sample Submission Profile Form

For static html form for printing, click here.   You may also download this form in Adobe portable document format to fill out off line by clicking here.

The following information is requested to assist EcoShield in pre-screening samples for recyclability potential. Though none of the information items are "required fields", the more information that is provided the easier it will be to make a positive pre-screening determination and accept the sample for testing.

You may print this page and when complete, fax this form to EcoShield at 877-326-9090, or mail to EcoShield Environmental Systems, P.O. Box 1476, Houston TX 77251.  After a positive determination is made you will be contacted for any additional information, notified of the next available testing schedule, and given shipping, packaging and sample collection method instructions.

Thank you for your interest in this program. If you have any questions regarding the form or the research program, please contact Mike McGinness at 877-326-7443.



*Name:     (* = required field)


Street Address:

Mail Address: 

City:    State:    Zip: 




Does your company have a written specification that cleaners must meet?  Yes  No

Process Description

Type of Washer (Immersion, Spray Washer, etc.): 

Manufacturer and Model of Washer: 

Tank Capacity: 

Brief Description of Parts Cleaned: 

Substrate Material (steel, aluminum, or type of other metal, plastic, composite, alloy, etc.): 

What is the next process after cleaning (plating, painting, milling, packaging, etc):  

Spent Cleaner Description

Cleaner chemistry description (manufacturer, cleaner type, production number): 

Is an MSDS or Technical Data Sheet available for the original cleaner? 

Actual use concentration of the cleaner at your facility: 

Soils or contaminants being removed: 

What is the quality of the sample to be submitted (almost new, operational, almost gone, expired or spent, etc): 

Operating temperature range: 

Operating pH range: 

How often does the cleaner need replacing: 

Please list the expected soils, contaminants and their relative concentration in the sample to be submitted (if known) (note: 10,000 = 1%):

Is the used cleaner considered to be hazardous waste when disposed of?  If yes, please list any known hazardous characteristics:

Additional Comments

Additional comments are welcome and appreciated. Any particular problems you have experienced or issues of particular interest to you in the performance of a cleaning system will assist our evaluation of the regeneration potential of your cleaner system:

Thank you for your interest in this research program.  When complete, please press the "submit" button below to submit your information.