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IeanHarbor <br />Z FERGUSON' <br />Nobody expects more from us than we do" <br />Ferguson Enterprises- Hazardous Waste Pickup Request Electronic Order Form <br />Form Instructions: <br />Fill in the Gray Colored Boxes. Provide as much detail as possible. Email the completed form to: FergusonretaiI@cleanharbors.com <br />Questions on this form: Contact Drew Hartsock at drew.hartsock@ferguson.com or 757-969-4725 <br />Ferguson Location Number 321 <br />Ferguson LOCATION STATE California <br />DATE OF REQUEST 8/31/2017 <br />Don't forget to include the SDS and photos of the waste if available! <br />Ferguson Contact Person Loralie Macasinag <br />Ferguson Contact Telephone (209) 943-8360 <br />Ferguson Contact Email Loralie.Macasinag@ferguson.com <br />Ferguson WASTE DESCRIPTION <br />PROFILE NUMBER <br />Quantity <br />(How many pieces of the waste item) <br />CONTAINER TYPE <br />(What kind of drum is the waste in: poly, steel, etc.) <br />Unit of Measurement (Size of container) <br />Accumulation Start Date (Date <br />Identified) <br />(D93165337) 15 LITER GLANCE GLS / <br />MULTI CLNR <br />2 <br />poly/plastic <br />1.32 gal <br />8/1/2017 <br />(D25053) COVE BSE ADHE QT <br />2 <br />poly/plastic <br />32 oz <br />8/1/2017 <br />(VP00000000Q-NR)QT VIC LUB <br />16 <br />poly/plastic <br />1 QT <br />8/1/2017 <br />(PSLUBXLIQ) 1 QT 2 LB PIPE JT LUB NSF <br />NEW FORM <br />36 <br />poly/plastic <br />1 QT <br />8/1/2017 <br />(1-11509) 32 OZ GEL HEAT DISSIPATING <br />SPRY <br />1 <br />poly/plastic <br />32 oz <br />8/1/2017 <br />(R74012) 1 GAL SS THRD OIL <br />1 <br />poly/plastic <br />1 gal <br />8/1/2017 <br />(PFM90037) 12 OZ POLY EXP INSUL <br />FOAM <br />9 <br />aerosol <br />12 oz <br />8/1/2017 <br />(D44242) 12 OZ POLYURE FIRE BLOCK <br />FOAM <br />3 <br />aerosol <br />12 oz <br />8/1/2017 <br />(030902) 32 OZ ABS BLK CMNT <br />12 <br />metal/steel <br />32 oz <br />8/1/2017 <br />(PPREP900EA) 5 GAL PAINT & COLORANT <br />SOLIDIFIER <br />2 <br />poly/plastic pail <br />5 gal <br />8/1/2017 <br />(DIVBY) *021116 COIL CLNR NON ACID <br />YELL <br />4 <br />poly/plastic <br />1 gal <br />8/1/2017 <br />(D904516) 1 *0216 5G BNB GP FRWD GP <br />CLNR <br />54 <br />box/poly/plastic <br />5 gal <br />5/2/2017 <br />(H35284) 5 GAL CRYOTEK 100 ANTI- <br />FREEZE <br />1 <br />poly/plastic pail <br />5 gal <br />8/1/2017 <br />(1,135285) SG CRYOTEK AG ANTI -FREEZE <br />Clean Harbors Container Code <br />Container Type <br />1 <br />Cost per Item <br />Additional Waste Infor`. <br />Order Supplies: <br />poly/plastic pail <br />Number of Containers/Items Needed <br />5 gal 8/1/2017 <br />Special Notes <br />DM55STL <br />55 Gallon Drum Reconditioned- DOT Rated <br />$ <br />55.00 <br />Hawaii Locations contact Drew Hartsock for pricing <br />DMSSPOLY <br />55 Gallon Poly Drum- DOT Rated <br />$ <br />75.00 <br />2 <br />Hawaii Locations contact Drew Hartsock for pricing <br />DM20POLY <br />20 Gallon Poly Drum- DOT Rated <br />$ <br />45.00 <br />Hawaii Locations contact Drew Hartsock for pricing <br />DMSPOLY <br />5 Gallon Poly Pail- DOT Rated <br />$ <br />16.00 <br />Hawaii Locations contact Drew Hartsock for pricing <br />VERMSORB <br />lVermiculite Absorbent <br />$ <br />19.00 <br />Hawaii Locations contact Drew Hartsock for pricing <br />BOXB <br />18 Foot Light Bulb Box <br />$ <br />20.00 <br />Hawaii Locations contact Drew Hartsock for pricing <br />BOX4 <br />14 Foot Light Bulb Box <br />$ <br />15.00 <br />Hawaii Locations contact Drew Hartsock for pricing <br />Driver Instructions: <br />