samples.htm_cmp_eco1000_bnr.gif (6299 bytes)


Used Aqueous Cleaner Regeneration Trial

Sample Submission Profile Form

For online form, 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.  You may also fill out and submit this form online.   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 ____________________________________________

Company ____________________________________________

Street Address ____________________________________________

Mail Address ____________________________________________

Phone ____________________________________________

Fax ____________________________________________

E-mail ____________________________________________

Does your company have a written specification that cleaners must meet? If so please send us a copy.


Process Description:

Type of Washer: __ Immersion, __ Spray Washer, __ Other ____________.

Manufacturer and Model # of Washer: _____________.

Tank capacity: _____________.

Briefly Describe Parts Being Cleaned: _____________________________ ____________________________________________________________.

Substrate material? __ Steel, __ Aluminum, __ Plastic, __ Composite, __ Alloy, __ Other Metal _____________, __ Other _____________.

What is the next process after cleaning (i.e. plating, painting, milling, packaging, please describe)? _____________________________________.


Spent Cleaner Description:

Cleaner chemistry description (manufacturer, cleaner type, product number): ____________________________________________________.

MSDS Technical Data Sheet of Original Cleaner: If available, please include with submission.

Actual Use Concentration of Cleaner at your facility: _________________.

Soils or contaminants being removed: _____________________________.

Will the sample submitted be: y new, y operational, or y expired (spent)?

Operating temperature range? ___________________________________.

Operating pH range? __________________________________________.

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



How often are you currently needing to replace the cleaner? ___________.

Is the used cleaner considered to be hazardous waste when disposed of? (Y/N) If yes, please list any known hazard 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:

Contact Information

Telephone ecologo.gif (3584 bytes)
Postal address
P.O. Box 1476, Houston Texas, 77251
Electronic mail
General Information, sales and support: