Title Ms Mr Last name (*) First name (*) Position Deputy Administrative Officer City Council Member Director General Director of Services Elected Official Mayor President Financial Manager IT Manager HR Manager Secretary General Secretary Other (specify) Company (*) Address (*) Additional address Post office box Postal code (*) City (*) Country (*) Telephone (*) Fax E-mail (*)

	Name Location (Country) Location (City) Date of submission of offer Date of decision Date of start of service

	Origin of water
	Type of water			Surface
		Lake, river		Underground
		Other, specify

	Flows	Unit	MINI	AVG	MAXI
	Net hourly flow	m3/h
	Net daily flow	m3/day
	Hourly flow for processing	m3/h
	Daily flow for processing	m3/day

	Composition chimique	Unit	MINI	AVG	MAXI
	Dissolved iron	mg/l
	Dissolved manganese	mg/l
	Dissolved aluminum	mg/l
	Temperature	°C
	pH	pH
	Turbidity	NTU
	(ou) MeS	mg/l
	Color	Pt-Co
	Oxidizability with KMnO4	mg KMnO4/l
	COT (Total Organic Carbon)	mg/l
	Pesticides	µg/l
	Algae	number/ml
	COD (Dissolved Organic Carbon)	mg/l
	UV Absorption to 254 nm

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(*) = obligatory

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