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8 ole<opy
<br />iF'OIS MEMORANDUM I
<br />tl pl Bala, cov¢il glhhp plliy named lh In and is ln�nd tlaolely lo�hlAn9 oollatord.d
<br />Shipper's No.
<br />Carrior%��s>� >'- �r r rr r. Lo -,r ,a% r:)/ s}=r'../, r e" SCAC Carrier's No.
<br />RECEIVED, suUlacl to Intlivldually do orminod teles or contracts Ihel haus b0en ngread upon 61 vrciling belrreen Ihe center and sMppar, II eppllcablo, olhonvlso to Ihe Isles, classlllcellonsend rulos Ihalhave Veen
<br />ealaUllshad Uy Iho eaular antl are avallabta lO lbs sMppar, on request; and all opplkeble stele and lederol reguleUons;
<br />at from �• . i <-' `)'71)
<br />)` /)..:1 •'-
<br />,date
<br />Ihe p(opedy descdbed below, to apparent good ordor, oxcepl na noted tcenlenls and condition of conlonls of paekagos unknavn), nloBod, consigned, and doslfned as Intllealed Uelow, erhbh aald company
<br />Ilhe mord company 6eing undaralaod Ihrou9ho�t this conlmct as moaning any parson or corporation In possosalon of Iho propody unUor Ihe contract) agrees to carry to delivOry aI eald UOsIh1n11on, II on Its
<br />route, of odlenvlse to deliver to onnlhar canlgero Iho roulo to said tlosllnallon. Il is mutually egroed as to each cn(darof nil or any of seltl Propoliy over ally yypodlon of sold roul0 to tlosllnallon, and as to
<br />each ppaady at any Irmo Inlorosled In nil or any of .said Properly Ilwl every s0ivlca 10 Un pednrmod hornunclar shall Ua suUlocl to all Iho condillons not prohibited by law,
<br />wholhor pllnleU or vnillen, IlOreln
<br />contained, Inclutlln91110 condillons on lho back horaol, which are horaU agreoU to Uy lha ship or anA uccoplod for himself and his assigns,
<br />TO:Ir// l /i/') L.f: �fC: /+ f r..
<br />FROM: 1.{a..�.. � t i ai ! � y:I(
<br />`., ._7..,�1)["r
<br />il)ic".•f( .'i.'J/.qtr,'
<br />Const noe
<br />SITZ er
<br />Street /O i- :r. ary '�'
<br />:� <.-./,, 9 r ':r.
<br />SlYeet
<br />J„;,)
<br />(:!
<br />DesQnaUon, �) .. �, :.; r: � < g ,,.1
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<br />Orl in iix'('/ i,,t/ (.,-�
<br />Zip r � �, �/ � _
<br />-
<br />.,
<br />Route
<br />'
<br />Delivering Carrier
<br />VehlDle Number
<br />U.S. DOT
<br />Nazmat Rog.
<br />No.
<br />0
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<br />IIYI 19i � I
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<br />,L�/..fur .......
<br />trr)(d(!r /ll telt) 'T Y'� r rI�/`,.Sll�u
<br />_x
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<br />...
<br />t
<br />+x' ,,
<br />Remit COD to:
<br />s„nlan is 9aallaa 1 oI coaQlleas, 01a1a
<br />wpmom la.a ha tlal;varatl IP wa oaaslgana
<br />Ihe IaOon iha
<br />AMT'
<br />COD �
<br />�
<br />eo® FEE:
<br />AddYess:
<br />lallh 1 recom¢o ce
<br />oa.°' �or<bml:'samomroam96ulemeab
<br />Pre old ❑
<br />p
<br />City' State' Zlp:
<br />Tia aa,der obeli rel make del\ery of Nis
<br />pnymanl of Irelghl antl oil
<br />ohor lanlcl
<br />�
<br />CoiIOC( ❑ .�
<br /><hwal
<br />Ues.
<br />NOTE: Where Ihe rete Ia dependent on value, shippers aro required to slate spaclgcally In vuiUnO
<br />TOTAL. CHARGES:
<br />FREIGHT CHARGES:
<br />Iho agreed or doctored value of Iho property. The agreed or declared valuo of Iho propody Is
<br />mm
<br />hereby speclllcally slated Uylhashlpper tohenol exceeding$ Per
<br />(sgrawroolcens'6nor)
<br />qs
<br />❑Propald ❑Collect
<br />No7El LlaUlllly Llnsllnllon for loss or damago In 1 Is sldpment may Ue applloabfe, See -0B U.S,C. ¢
<br />ig7aao 1 A D.
<br />❑OY ❑9V
<br />and .. s
<br />' � 1
<br />SIiIPPEp CAPAI[N
<br />This Is le mNly Thal iho abova�lhaned mnloiialo ai0 pi0i0ily clncalllnd, doscdbcd, packagod, nmtkcd
<br />noel fnbolOA, antl nio In propor eontliilon fog Inlnopmlallon Oc<oh11nU to Iho opplicnblo iefadallona of ! 1 OUIVEfl'8
<br />Iho Depallmonl of Trnnspalnl'.On, pnr SIONATUNE:
<br />SHIPPER �. y7a i �r. ' •-�:�� .: �7:.x':' CARRIERI/tJ1t.. � :�..- 11':� �,,.,: �r..,
<br />`.l.:i,'rC'�,'
<br />PER:_ S :�� ...,. PATE. r.. , ,. �,r r '.PER. I ; 1 I ��
<br />DATE. � 1' :r /
<br />. •
<br /><
<br />.
<br />EMERGENCY RESPONSE � NAME Ott CONTRA T NUMBER
<br />.
<br />TELEPHONE NUMBER: (` r//, `' r `T L�,�r OR OTHER UNIQUE IbENTIPIER:
<br />\'
<br />'JG'J (Rev. 3/17} �
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