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Nalco Water Order Form
Your Name:
*
Email Address:
*
Your Phone #:
*
District:
*
Location?:
*
United States
Canada
Order Type:
*
Empty Container Request
Label Order Request
Sample Order Request (Chemical)
All other order types to be placed through the eCommerce/Connect portal:
https://connect.ecolab.com/
Empty Container requests will be processed as a YNC-No Charge Order to customer
Sample requests will be processed as a YSD-Sale to District
Charge to District Cost Center or BA?
*
Sale to District
Customer BA
Territory Number:
Charge Code:
*
Sold-To Number:
*
Ship-To Number
(if multiple ship to #'s exist):
BA Number (if multiple BA's exist):
Reason:
Cross Dock?:
Yes
Cross Dock District & Territory:
Cross Dock to Customer - Ship-To Number:
Customer Name:
Delivery Contact:
*
Use SAP Permanent Contact
New Contact
Delivery Contact:
*
Phone Number:
*
Sales Charge Code?
Yes
Service Charge Code?
Yes
Will any of these items need to be rushed?:
*
Yes
No
EMPTY CONTAINER
1. Container Size:
*
.11 - 5 GAL PAIL
.12 - 15 GAL DRUM
.15 - 55 GAL DRUM
.56 - 55 GAL RECYCLABLE DRUM
.61 - 275 GAL TOTE
Quantity:
*
Chemical:
*
Labels needed?:
Yes
Add Another Container?:
Yes
2. Container Size:
*
.11 - 5 GAL PAIL
.12 - 15 GAL DRUM
.15 - 55 GAL DRUM
.56 - 55 GAL RECYCLABLE DRUM
.61 - 275 GAL TOTE
Quantity:
*
Chemical:
*
Labels needed?:
Yes
Add Another Container?:
Yes
3. Container Size:
*
.11 - 5 GAL PAIL
.12 - 15 GAL DRUM
.15 - 55 GAL DRUM
.56 - 55 GAL RECYCLABLE DRUM
.61 - 275 GAL TOTE
Quantity:
*
Chemical:
*
Labels needed?:
Yes
Add Another Container?:
Yes
4. Container Size:
*
.11 - 5 GAL PAIL
.12 - 15 GAL DRUM
.15 - 55 GAL DRUM
.56 - 55 GAL RECYCLABLE DRUM
.61 - 275 GAL TOTE
Quantity:
*
Chemical:
*
Labels needed?:
Yes
Add Another Container?:
Yes
5. Container Size:
*
.11 - 5 GAL PAIL
.12 - 15 GAL DRUM
.15 - 55 GAL DRUM
.56 - 55 GAL RECYCLABLE DRUM
.61 - 275 GAL TOTE
Quantity:
*
Chemical:
*
Labels needed?:
Yes
SAMPLE REQUEST
1. Sample Size:
*
2 oz. - 50 ML
1 L - 1,000 ML
Chemical:
*
Quantity:
*
Add Another Sample?:
Yes
2. Sample Size:
*
2 oz. - 50 ML
1 L - 1,000 ML
Chemical:
*
Quantity:
*
Add Another Sample?:
Yes
3. Sample Size:
*
2 oz. - 50 ML
1 L - 1,000 ML
Chemical:
*
Quantity:
*
Add Another Sample?:
Yes
4. Sample Size:
*
2 oz. - 50 ML
1 L - 1,000 ML
Chemical:
*
Quantity:
*
Add Another Sample?:
Yes
5. Sample Size:
*
2 oz. - 50 ML
1 L - 1,000 ML
Chemical:
*
Quantity:
*
LABEL REQUEST
Please Select:
*
Bulk
Bulk Fill Line Label
Bulk Fill Line Board
Portafeed
EVD
1. Bulk Part #:
*
241-P3317.88 - Bulk Tank Label Complete Kit
241-P3320.88 - Bulk Tank Kit with Labels, Mylar, Fill-line, SDS
# of Labels:
*
Product:
*
Capacity:
*
Tank Number:
*
Add Another?:
Yes
2. Bulk Part #:
*
241-P3317.88 - Bulk Tank Label Complete Kit
241-P3320.88 - Bulk Tank Kit with Labels, Mylar, Fill-line, SDS
# of Labels:
*
Product:
*
Capacity:
*
Tank Number:
*
Add Another?:
Yes
3. Bulk Part #:
*
241-P3317.88 - Bulk Tank Label Complete Kit
241-P3320.88 - Bulk Tank Kit with Labels, Mylar, Fill-line, SDS
# of Labels:
*
Product:
*
Capacity:
*
Tank Number:
*
Add Another?:
Yes
4. Bulk Part #:
*
241-P3317.88 - Bulk Tank Label Complete Kit
241-P3320.88 - Bulk Tank Kit with Labels, Mylar, Fill-line, SDS
# of Labels:
*
Product:
*
Capacity:
*
Tank Number:
*
Add Another?:
Yes
5. Bulk Part #:
*
241-P3317.88 - Bulk Tank Label Complete Kit
241-P3320.88 - Bulk Tank Kit with Labels, Mylar, Fill-line, SDS
# of Labels:
*
Product:
*
Capacity:
*
Tank Number:
*
1. Bulk Fill Line Label
*
Bulk Fill Line Label - 241-P3374.88
# of Labels:
*
Product:
*
Capacity:
*
Tank Number:
*
Add Another?:
Yes
2. Bulk Fill Line Label
*
Bulk Fill Line Label - 241-P3374.88
# of Labels:
*
Product:
*
Capacity:
*
Tank Number:
*
Add Another?:
Yes
3. Bulk Fill Line Label
*
Bulk Fill Line Label - 241-P3374.88
# of Labels:
*
Product:
*
Capacity:
*
Tank Number:
*
Add Another?:
Yes
4. Bulk Fill Line Label
*
Bulk Fill Line Label - 241-P3374.88
# of Labels:
*
Product:
*
Capacity:
*
Tank Number:
*
Add Another?:
Yes
5. Bulk Fill Line Label
*
Bulk Fill Line Label - 241-P3374.88
# of Labels:
*
Product:
*
Capacity:
*
Tank Number:
*
Bulk Fill Line Board
*
Bulk Fill Line Board - 241-P3372.88 - 8x5 Board ONLY
Quantity:
*
1. EVD QR Code Label
*
EVD QR Code Label - 241-P3389.88
# of Labels:
*
Product:
*
Tank Number:
*
Equipment Number:
Add Another?:
Yes
2. EVD QR Code Label
*
EVD QR Code Label - 241-P3389.88
# of Labels:
*
Product:
*
Tank Number:
*
Equipment Number:
Add Another?:
Yes
3. EVD QR Code Label
*
EVD QR Code Label - 241-P3389.88
# of Labels:
*
Product:
*
Tank Number:
*
Equipment Number:
Add Another?:
Yes
4. EVD QR Code Label
*
EVD QR Code Label - 241-P3389.88
# of Labels:
*
Product:
*
Tank Number:
*
Equipment Number:
Add Another?:
Yes
5. EVD QR Code Label
*
EVD QR Code Label - 241-P3389.88
# of Labels:
*
Product:
*
Tank Number:
*
Equipment Number:
Add Another?:
Yes
6. EVD QR Code Label
*
EVD QR Code Label - 241-P3389.88
# of Labels:
*
Product:
*
Tank Number:
*
Equipment Number:
Add Another?:
Yes
7. EVD QR Code Label
*
EVD QR Code Label - 241-P3389.88
# of Labels:
*
Product:
*
Tank Number:
*
Equipment Number:
Add Another?:
Yes
8. EVD QR Code Label
*
EVD QR Code Label - 241-P3389.88
# of Labels:
*
Product:
*
Tank Number:
*
Equipment Number:
Add Another?:
Yes
9. EVD QR Code Label
*
EVD QR Code Label - 241-P3389.88
# of Labels:
*
Product:
*
Tank Number:
*
Equipment Number:
Add Another?:
Yes
10. EVD QR Code Label
*
EVD QR Code Label - 241-P3389.88
# of Labels:
*
Product:
*
Tank Number:
*
Equipment Number:
1. Portafeed Part #:
*
241-P0208.88 - Label Overlay
881-P3368.88 - Non-Biocide Label
881-P3369.88 - Biocide Label
# of Labels:
*
Product:
*
Add Another?:
Yes
2. Portafeed Part #:
*
241-P0208.88 - Label Overlay
881-P3368.88 - Non-Biocide Label
881-P3369.88 - Biocide Label
# of Labels:
*
Product:
*
Add Another?:
Yes
3. Portafeed Part #:
*
241-P0208.88 - Label Overlay
881-P3368.88 - Non-Biocide Label
881-P3369.88 - Biocide Label
# of Labels:
*
Product:
*
Add Another?:
Yes
4. Portafeed Part #:
*
241-P0208.88 - Label Overlay
881-P3368.88 - Non-Biocide Label
881-P3369.88 - Biocide Label
# of Labels:
*
Product:
*
Add Another?:
Yes
5. Portafeed Part #:
*
241-P0208.88 - Label Overlay
881-P3368.88 - Non-Biocide Label
881-P3369.88 - Biocide Label
# of Labels:
*
Product:
*
Special Instructions: