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THIS MEMORANDUM is an acknowledgment that a bill of lading has been issued and is not the Original Bill of Lading,nor a copy or duplicate,covering the property named herein,and is intended solely for filing or record. SHIPPER NO. CARRIER NO. DATE BARRIER SCAC TO FROM CONSIGNEE SHIPPER STREET STREET DESTINATION STATE ZIP ORIGIN STATE ZIP ROUTE VEHICLE NUMBER U.S. DOT Hazmat Reg.No. Number and Type HM Description of Articles Class or t i of Packages Rate t - �- Subject Section 7 of conditions,if thi COD FEE s Remit COD to: •shipment is too be delivered the consignee COD AMT: ' without recourse on the consignor,the consignor Address: shall sign the following statement: p The carrier shY not make delivery of this City: State: Zip: shipmentPrepaid without a ment of freight and all other Collect ❑ NOTE:Where the rate is dependent on value,shippers are required to state specifically in writing the lawful changes. TOTAL CHARGES: agreed or declared value of the property.The agreed or declared value of the property is hereby FREIGHT CHARGES: specifically stated by the shipper to be not exceeding$ Per (Signature of Consignor) ❑ Prepaid ❑Collect 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;the Property described above,in apparent good order,except as noted(contents and condition of contents of packages unknown),marked,consigned,and destined as indicated above 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. NOTE:Liability Limitation for loss or damage in this shipment may be applicable.See 49 U.S.C.14706(c)(1)(A)and(B). 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 reg6lations of the Department of Transportation PER: Ingenium 6,dcrafnento tslbtruuu- SHIPPER: CARRIER: ) PER: PER: DATE: EMERGENCY RESPONSE NAME OR CONTRACT NUMBER TELEPHONE NUMBER: OR OTHER UNIQUE IDENTIFIER: WAKE #4120 (800)878-4919 (REV 6/2019) 3