Bulk Washer Solvent & Coolant Set Up Form Account #* Company Name* Ship To #* Address* Street Address City State / Province / Region ZIP / Postal Code Contact Name* First Last PhoneEmail* Brenntag Lubricants Sales Rep* First Last Brenntag Lubricants 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/MonthConventionalUniversalExt. Life OrangeHD Ext. LifeHD Ext. Life NF Frequency for Refills Weekly, Monthly, etc. (Minimum annual target 750 gallons)Windshield Washer FluidCheck One Yes No Approx. Usage/MonthWasher 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 CommentsUntitled Untitled
