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THIS MEMORANDUM Is an acknowledgement that a bill of lading has been issued and is not the Original Bill of Lading, not a copy or duplicate, covering the property named herein, and is intended solely for filing or record. Shipper' s No . i Carrier � � SCAC Carrier' s No . J � m .� > 1 ,� �� r • � �N � , �i` r"t ' RECEIVED, subject to individually determined rates or contracts that have been agreed upon in writing between the carrier and shipper, if applicable, otherwise to the rates, classifications and rules that have been established by the carrier and are available to the shipper, on request; and all applicable state and federal regulations; at , date from the Property described below, in apparent good order, except as noted (contents and condition of contents of packages unknown), marked, constgne nd destined as indicated below, 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 said destination, if on its route, or otherwise to deliver to another carrier on the route to said destination. It 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 every 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 and his assigns. TO : FROM : II Consignee =S T e/fti.r x141 5::� r/r^l � � Shipper E"r .vi1e� o 1 t T 0t9 ) L14` rf P4 ` Street / yti 4/ crJ 1 Street / e) / S` Nig ✓ E Destination f 4r09 Zi / 4e) 1 Origin S {fir " e-:4� �` ? Zip <j � 2U G" Route i Delivering Carrier Vehicle Number U . S . DOT Hazmat Recd . No . LL LDescription yr I I I i i - I i I i - - i - i I � ��/1AfJar , !? t'� � ✓r /I�.� j SubieSection of conditions, if this COD FEE . ® D AMT :COD t0 : shipment iss too bdelivered ed tthe consignee MT : without recourse consignor,on the consignor, the Address : consignor shall sign the following statement: - Prepaid ❑ The carrier shall not make delivery of this City : State : Zip : shipment without payment of freight and all $ Collect ❑ other lawful charges. NOTE: Where the rate is dependent on value, shippers are required to state specifically In writing TOTAL CHARGES : FREIGHT CHARGES : the agreed or declared value of the property. The agreed or declared value of the property is hereby specifically stated by the shipper to be not exceeding $ Per (signature of consignor) $ Q Prepaid ❑ Collect NOTE: Liability Limitation for loss or damage in this shipment may be applicable. See 49 U.S.C. 14706 c 1 A and B . • • g 11BY SHIPPER [] BY CARRIER ! This is to certify that the above-named materials are properly classified, described, packaged, marked and labeled, and are in proper condition for transportation according to the applicable regulations of g DRIVEfl'S i the Department of Transportation. Per SIGNATURE: S H I P P E I It t /4t ,r Aim / CARRIER : 1� � a N� f Y► 7f-�. S^� tJ� C�`r--k % DATE :J - �/ - s'3 J `c-f ER : DATE : !moi k r EMERGENCY RESPONSE / r� NAME OR CONTRACT NUMBER TELEPHONE NUMBER : ` � 3 1- 7� OR OTHER UNIQUE IDENTIFIER : 969 (Rev. 3/17)