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Bulk Washer Solvent & Coolant Set Up Form
Account #
*
Company Name
*
Ship To #
*
Address
*
Street Address
City
State / Province / Region
ZIP / Postal Code
Customer Contact Info
*
First
Last
Phone
GHB Sales Rep
*
First
Last
GHB Sales Rep Email
*
Product A/F
*
Check One
PROCV02-PB (Conventional)
PROHY01-PB (Universal)
PROEL03-PB (Extended Life Orange)
PROEL09-PB (Extended Life Blue)
PROEL06-PB (Extended Life Pink)
PROHDN05-PB (HD ELC NOAT Strawberry)
PROHDNF04-PB (HD ELC OAT Red)
PROGLB01-PB (Extended Life Global)
PROCV07-PB (Conventional HD Fuchsia)
WWFRUTUBULK (-20 All Season)
Pick Up Waste AF at Time of Delivery
NA
Each Requested Product Approx. Usage/Month
Conventional
Universal
Ext. Life Orange
HD Ext. Life
HD Ext. Life NF
Frequency for Refills
Weekly, Monthly, etc. (Minimum annual target 750 gallons)
Windshield Washer Fluid
Check One
Yes
No
Approx. Usage/Month
Washer Fluid
Frequency for Refills
Weekly, Monthly, etc. (Minimum annual target 1250 gallons)
Transfer from Old Tank to New Tank?
check one
Yes
No
Install Tank?
check one
Yes
No
Install Pump?
check one
Yes
No
Size Tank?
New York Only 165 Gals
CT, RI, MA 165 Gals
CT, RI, MA 200 Gals
Customer Owned Tanks?
check one
Yes
No
Waste AF Drum Left with Customer?
check one
Yes
No
How Many?
Additional Comments