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<br /> THIS MEMORANDUM leanacknowbdgaoam the'ablll"Ming has been leeued and Is net the 009WAI Bill pf Lading nor
<br /> a copy or tluplicxe,covering the property nexaAM1arxry erx la hderxedadby lm flling or re¢ore. SHIPPER NO.
<br /> fr `i 5 '•tit.-:•r.ii.,Y v x . ..,...I CARRIER NO.
<br /> .AHRIER DATE �•^ r`
<br /> TO SCAC
<br /> CONSIGNEE 4� FROM
<br /> SHIPPER
<br /> ?:Y-..7'!1: :tk}Hrtt vi:•)13` .�:ixv'r'15 f1rF.3'tl16C51
<br /> STREET �,.I rt,. • 4r:;.gays. STREET
<br /> f-11:5'-^.-w<'' :u�l:.>•4•! y�,
<br /> DESTINATION t .e.,
<br /> STATE ZIP ORIGIN :att)I.P.t4xa-. CA WS•I•ATE ZIP
<br /> ROUTE VEHICLE NUMBER
<br /> U.S.DOT Hazmat Reg.Na.
<br /> DtDCtIrtelird 03bNti Seim evdim i bbo
<br /> DescriptionNumber and Type
<br /> f-Iras;Yf1cf, T I lift, lu" fJW.71VM'RACfWk LraY.fY?: Q A=afl—e r—
<br /> k-/ Tvas C/
<br /> ker-x�veti FIV: Dtate:
<br /> Remit COD to: sM.,to secdod]a,eanaabna•It this COD FEE
<br /> mpm•n Is to be dellmnd m the conaymo COD AMT:
<br /> 4ddfeSS: mm ro-aa on Ma�g�.mea o
<br /> amadwmobaaelnoalme.
<br /> ,I State: ma eamar",not mxe ae'aey d Mb $ Prepaid ❑
<br /> Z =e paarwde W:e,dee " W Collect ❑$
<br /> WE:Where the rate's dapendent on value,shlppere xe required to MW apeoficely in vrtitlng the asenfavTOTAL CHARGES:
<br /> greed or declared value of ate property.The agreed or disclosed value of the Properly Ia hereby G FREIGHT CHARGES
<br /> pecficollimated by Ne a hipper to be not ekoanong s Per Ipnemre of CanNvaO W
<br /> ECEIVEo,aegearolmldduauv desmdnee rales MLrenpeas Mx neve Been agreed Won In wrlarq between the tamer and Al er,n ❑Pr aid ❑Cogedt
<br /> dire aM1gger,on reaupx,and x appfi®bb aMb and ledmdl reguledons;Me Property,tlevalh¢d above,a a pp epplkaae,omerebe M pre retw,Wavficadore aM rules Mel Irav¢oxen e•IabfiaM1ed dY eumaer end ere ava�lx
<br /> save wM1itlr slid evmpvry and
<br /> so nest s heap d reassmod m.Voa.; Mk conhea as meaning roresnt,aad order,eeme as noted(eavion a and condMon M mnhnb of peakag¢s uMmownl,Mar[m,conLgnsof end de fired as indimr
<br /> OW to shM6r®aeron me rare to said des,,,o,,n a m,M¢A o any parsed or mr evernaos a devenoreW do or the golndy urMer Ma conlydc[)agrear ro orry M de0wry al said dastinetlm,it m iq ryab,or otlprvi ge
<br /> avka to be dormed M1emmreraMll be Yagnedastoemhematal,traded or Wtl PmpsMavaous .Indoi,of toroeba damnatlon and as b eaah Asti,x any tMn hosested ld ell or vry a Yq pro an
<br /> algna sugectmel Mewr-0Idons MlpmM1ldiletl by lax.wM1eMuprabtlprwdden,M1arein wnWned,Induyrg the mnxaure on Me pack hereat,at are M1ereby agreed to by Meablpper and a.,IW I.,=rel
<br /> b1E I-Imoday unseaflon far loan or damage In Ihb shlpmxa may be applicable.See 4B U.S.C.147me)(IXA)and(a).
<br /> his is to ceftlry that the above-named materials are properly classified,described,packaged,marked,and labeled,and
<br /> B In proper condition for transportation according to the applicable regulations of the Department of Transportation PER:
<br /> HIPPER: CARRIER: 57 /a--I.
<br /> .R: PER: Rq.•g.-- ,fr»�''�`�,
<br /> DATE: --
<br /> MERGENCY RESPONSE NAME OR CONTRACT NUMBER
<br /> ELEPHONE NUMBER: OR OTHER UNIQUE IDENTIFIER:
<br /> -BLC-03 12267(Rev.9/10) ��
<br />
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