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SHIPPER NO, <br /> must A filled in,in Ink,in Indelible Pencil,or in <br /> THIS SHIPPING ORDER m Carbon,and retained by the Agent. CARRIER NO. <br /> RECEIVE,subject to the classifications and tariffs in effect on the date of the issue of this Shipping Order. <br /> DATE: <br /> .ME OF CARRIER) (SCAC) <br /> FROM <br /> SHIPPER <br /> )NSIGNEE <br /> STREET <br /> 'BEET— itt <br /> WINATIONSTATE ZIP..';'�"� ORIGIN 2.1. 41/ STATE ZIP J_ <br /> U.S.DOT Hazmat Reg.No. VEHICLE NUMBER <br /> )UTE: <br /> gg <br /> A <br /> 'J <br /> f44 <br /> C.O.D.Fee: <br /> MIT C.O.D.TO: <br /> DRESS: CODAMT: $ PREPAID El <br /> Y. STATE ZIP COLLECT ❑ $ <br /> te.-where the rate is dependent on value,shippers are required to state Subject to Section 7 of conditions of applicable bill of lading, if this TOTAL <br /> )cifically in writing the agreed or declared value of the property. shipment is to be delivered to the consignee without recourse on the <br /> consignor,the consignor shall sign the following statement: CHARGES: $ <br /> agreed or declared value of the property is hereby specifically stated by The carrier shall not make delivery of this shipment without payment of FREIGHT CHARGES <br /> shipper to be not exceeding per freight and all other lawful charges. Freight Prepaid Check box <br /> except when If charges <br /> ty g <br /> TE:LiabiliLimitation for loss or dame In this shipment may be box at right to be <br /> m <br /> Alcable.See 49 U.S.C.14706(c)(1)(A)and(B). (signatum of Esignor) is checked 0—collect <br /> EIVED,subject to Individually determined rates or Contracts that have been agreed upon In writing between the carrier and shipper,it applicable,otherwise to the rates,classifications and rules that have been established by the carrier and are av"a <br /> shipper,on request;and all applicable state and federal regulations;the Property described below,in apparent good order,except as noted(contents and condition of contents of packages unknown),marked,consigned,and destined as Indicated <br /> i which said company(the word company being understood throughout this contract as meaning any person or corporation In possession of the property under the contract)agrees to carry to delivery at sald destination,If on its route,or otherwise to <br /> ir to another carrier on the route to said destination.11 Is mutually agreed as to each carrier of all or any of said Property over all or any portion of said route to destination and as to each party at any time interested in all or any of said Property that <br /> service to be performed hereunder shall be subject to all the conditions not prohibited by law,whether printed or written,herein contained,Including the conditions on the back hereof,which are hereby agreed to by the shipper and accepted for himself <br /> ,is assigns. <br /> 3 is to certify that the above-named materials are properly classified,described,packaged,marked and labeled,and <br /> in proper condition for transportation according to the applicable regulations of the DeDartment of marked,and <br /> PER: <br /> PPER: CARRIER: <br /> -7 <br /> PER. <br /> DATE' <br /> ERGENCY RESPONSE MONITORED AT ALL TIMES THE HAZARDOUS MATERIAL IS IN TRANSPORTATION <br /> LEPHONE NUMBER: INCLUDING STORAGE INCIDENTAL TO TRANSPORTATION.(172.604) <br /> (,@p.Agent must detach and retain this Shipping Order <br /> and must sign the Original Bill of Lading. <br /> FORM NO.1 1-BLC-04 536(Rev.11/04) <br />