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7 t hi,* iun 1 01111.11- UI' LAUIIMU—UMIURNIAL—IVU I rvcav i 11ADLG Shipper's No. Carrier SCAC Carrier's No. RECEIVED,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,classilicallons 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 fro C.r`7 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 below,w ch 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 Properly 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: Consignee �G Shipper LG Street LA L % Street 5L eo i L Destination zipOrigin I Zi � v1Z d Route Delivering Carrier Vehicle Number U.S. DOT Hazmat Reg. No. MOM LT'D 'IIIb 2C1 Z - die(20�4,qdCIS�tll/i ,SSi�Ji' Subject to Section 7 of conditions,If this Remit COD to: shipment Is to be delivered to the consignee COD FEE: �® AMT: • without recourse on the consignor, the Address: constnor shall sign the following statement: Prepaid ElTho canter shall nor make delivery of this r� City: State: Zip: shipment without payment of Imlgbt end all Collect ElW 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 S Per (Signature of consign -]Prepaid ❑collect NOTE:Llobllity Limlletion for loss or damage In this shipment may be applicable.See 49 U.S.C. •s 14708 c )(1)(A)and(B). ,e .. w ❑BY SHIPPER BY CARRIER This Is to certify the(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 ! DRIVER'S the Department of Transportation.Per 7 SIGNATURE: SHIPPER: RRIE PER: DATE: PER: DATE: EMERGE CY RES N NAME OR CONTRA NUMBER TELEPHONE NUMBER: OR OTHER UNIQUE IDENTIFIER: 969(Rev.3/17)