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Es an acknowledgement that a bili of ladjng has been Issued and is not the Original 9111 of Lading, not a copy THIS MEMORANDUM or duplicate, covering the property named herein, and is intended solely for filing or record. i 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, classifications and rules that have been established by the carrier and are available to the shipper, an request; and all applicable state and federal regulations; at date from I ' 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, 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: -ConsigneerShipper Street i 5;'. , , Street Destination 7ir, Origin zip Route Delivering Carrier Vehicle Number U.S. DOT Hazmat Reg, No. NumberNumber and Type of Packages HM Description of Articles �L7 C T Z/- k ..i.� f Remit COD til Subject to Seclicn 7 of conditions, if this /� CSD ��: ,.1,,1 shipment is to be delivered to the consignee r -0 D AMT: Address. without recourse on the monsignor, the y consignor shall sign the following statement: Prepaid Ci},� C+ The carrier shall not make delivery of this ❑ ty. State: Zip: shipment without payment of freight and ail Yh ❑ other lawful charges. Collect 4$ 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 (Signawre of consignarj I $ ❑ Prepaid ❑ f olieci NEOTE: Llabllity Limitation fQriloss or damage in this shipment may be applicable. See 49 U.S.C. 14706c)(y)(A)ana (B . This is to certify That the above-named materials are properly cfassitied, described, packaged, marked 1 ❑ BY SHIPPER []BY CARRIER and labeled, and are A proper condition for transportation according to the applicable regulations of DRIVER'S the Department of'Tr&n4perlatiori. Per SIGNATE'. UR / r SHIPPER I?4-1� ,< CARRIER: ,: _ F Ii , �Il , r PER: /;� f , DATE: PER: DATE: EMiWG'tNCY RESPONSE NAME OR CONTRACT NUMBER TELEPHONE NUMBER: (�lu �,��-S 1fi OR OTHER UNIQUE IDENTIFIER: 969 (Rev. 3/117)