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Ieanftbor� 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: Fergusonretail@cleanharbors.com Don't forget to include the SDS and photos of the waste if available) <br /> Questions on this form:Contact Drew Hartsock at drew.hartsock@ferguson.com or 757-969-4725 <br /> Ferguson Location Number 321 Ferguson Contact Person Loralie Macasinag <br /> Ferguson LOCATION STATE California Ferguson Contact Telephone (209)943-8360 <br /> DATE OF REQUEST 8/31/2017 Ferguson Contact Email Lora lie.Macasinag@ferguson.com <br /> Quantity CONTAINERTYPE Accumulation Start Date(Date <br /> Ferguson WASTE DESCRIPTION PROFILE NUMBER (How many pieces of the waste item) (What kind of drum is the waste in: poly,steel,etc.) Unit of Measurement(Size of container) Identified) <br /> (D93165337)15 LITER GLANCE GLS/ <br /> MULTI CLNR 2 poly/plastic 1.32 gal 8/1/2017 <br /> (D25053)COVE BSE ADHE QT 2 poly/plastic 32 oz 8/1/2017 <br /> (VP00000000Q-NR)QT VIC LUB 16 poly/plastic 1 QT 8/1/2017 <br /> (PSLUBXLIQ)1 QT 2 LB PIPE JT LUB NSF <br /> NEW FORM 36 poly/plastic 1 QT 8/1/2017 <br /> (1-11509)32 OZ GEL HEAT DISSIPATING <br /> SPRY 1 poly/plastic 32 oz 8/1/2017 <br /> (R74012)1 GAL SS THRD OIL 1 poly/plastic 1 gal 8/1/2017 <br /> (PFM90037)12 OZ POLY EXP INSUL <br /> FOAM 9 aerosol 12 oz 8/1/2017 <br /> (D44242)12 OZ POLYURE FIRE BLOCK <br /> FOAM 3 aerosol 12 oz 8/1/2017 <br /> (030902)32 OZ ABS BLK CM NT 12 metal/steel 32 oz 8/1/2017 <br /> (PPREP900EA)5 GAL PAINT&COLORANT <br /> SOLIDIFIER 2 poly/plastic pail 5 gal 8/1/2017 <br /> (DIV8Y)'0211 IG COIL CLNR NON ACID <br /> YELL 4 poly/plastic 1 gal 8/1/2017 <br /> (D904516)1'0216 SG BNB GP FRWD GP <br /> CLNR 54 box/poly/plastic 5 gal 5/2/2017 <br /> (H35284)5 GAL CRYOTEK 100 ANTI- <br /> FREEZE 1 poly/plastic pail 5 gal 8/1/2017 <br /> (H35285)5G CRYOTEK AG ANTI-FREEZE 1 poly/plastic pail 5 gal 8/1/2017 <br /> Additional Waste Informatf <br /> Order Supplies? <br /> Clean Harbors Container Code Container Type Cost per Item Number of Containers/Items Needed Special Notes <br /> DM55STL 55 Gallon Drum Reconditioned-DOT Rated $ 55.00 Hawaii Locations contact Drew Hartsock for pricing <br /> DM55POLY 55 Gallon Poly Drum-DOT Rated $ 75.00 2 Hawaii Locations contact Drew Hartsock for pricing <br /> DM20POLY 20 Gallon Poly Drum-DOT Rated $ 45.00 Hawaii Locations contact Drew Hartsock for pricing <br /> DMSPOLY 5 Gallon Poly Pail-DOT Rated $ 16.00 Hawaii Locations contact Drew Hartsock for pricing <br /> VERMSORB Vermiculite Absorbent 5 19.00 Hawaii Locations contact Drew Hartsock for pricing <br /> BOX8 8 Foot Light Bulb Box $ 20.00 Hawaii Locations contact Drew Hartsock for pricing <br /> BOX4 14 Foot Light Bulb Box $ 15.00 Hawaii Locations contact Drew Hartsock for pricing <br /> Instructions: <br />