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SHIPPER <br />g <br />DELIVERY DATE <br />JOR #;• �) � <br />SHIPPER/ CUSTOMER <br />- <br />POINT OF CONTACT <br />if t t"rj?ryi Irl' tti-i 1 ' <br />ADDRESS <br />PHONE# <br />Irrl "<r.I N 4A r'.I6r <br />CITY, STATE, ZIP <br />CARRIER/TRANSPORTER <br />PHONE# <br />CONSIGNEE FACILITY <br />POINT'' OF CONTACT <br />r i:= <br />_�---�- <br />ADDRESS �- <br />PHONE4 <br />ati ,'s+; :I• I,"Itti"� <br />;s €e t'-r�E--si �1;?' <br />CIN, STATE, ZIP <br />HM US DOT Description.(Including Proper Shipping Name, Hazard Class, and ID Number)DOM <br />Containers Total - <br />Quantity <br />N4 TYPO <br />A <br />B <br />C. <br />D <br />Special Handling Instruction and Additional information <br />4i4 .(.ti v'<:i)- <br />-'Ir 'r!}T[)tt' <br />t J <br />Placards Provided YES NO <br />SHIPPER'S CERTIFICATION: "I hereby declare that the contents of this consignment are fully and accurately <br />described above by proper shipping name and are classified, <br />packaged, marked and labolled/placarded, and are in all respects <br />in proper condition fer transport according <br />to applicable international and national governmental regulations," <br />I also certify that all times listed above are true and correct <br />(SHIPPER) PRINT OR TYPE NAME t <br />SIGNAU EMONTH <br />DAY <br />Y,AR <br />x' -1�` n'( 1� 6 S j <br />xv_"!` <br />1 <br />(_) j <br />imp <br />l(l <br />(CARRIE 1TA RY&R) PRINT ORTYPE NAME - <br />SIGNAI'• t -- <br />MONTH <br />DAY <br />YEAR <br />IE <br />(CONSIGNEE/FACILITY) PRINT OR TYPE NAME <br />SIGNATURE <br />MONTH <br />DAY <br />YEAR <br />x <br />x <br />SHIPPER <br />g <br />