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----------- if IYICIYlVIf1M1YILJUltf1 is an w6owledgement that a bill of lading hm been issued and to not the Odglnnl Bill or Lading,nor - Shippers No. a copy a£duplicate,covering the property named hmin,and in Intended solely for filing or record. ,.- v Carrier's No. CARRIER: r SCAC Date TO: FROM: nsignee ' go j Shipper. K WU77 ' v 1„� 14, Street Street Destination Zipc S Origin P Zip• Route: Vehicle Number U.S. DOT Hazmat Reg. Na. Number of 0 VvEIGHT Shipping Description of articles, special marks, and exceptions .- Units HIM correction) Remit C.O.D.to: COD C. 0. D. FEE: TOTAL CHARGES: Address: Prepaid❑ City- State: Zip: AMT: $ Collect ❑ $ 'if the shipment moves between two ports by a carrier by water,the law requires that the Subject to Section 7 of conditions d this shipment is to be delivered to the oonslgnas without bill of lading shall slate whether tf is"rarrieYs or shipper's weight'. racourse on the coreignor,the consig,wr shall sign the fdlowing slaternent FREIGHT CHARGES Note,-where the rate is dependent on value,shippers are required to state specifically In The carder shall rwl make delivery of this shipment without payment ol freight and as other lawful FREIGHT PREPAID writing the agreed or declared value of the property. charges. Except when CHECK BOX The agreed or declared value at the property Is hereby specifically stated by the shipper box at right1:1 if charges,are to be not exceeding per (Signature of Consignor) Is checked to be collect AECEIVED,subject to the classifications and tariffs in effect on the dale of this Bill of Lading,the property described above in apparent good order,except as noted(contents and condition of contents of packages udmown), marked,consigned,and destined as indicated above,which said company(the word company being understood Utroughout this contract as meaning any person or corporation In possession of the property under the contract)agrees to racy to its usual place of delivery at said destination,ti on ity own road or Ile own water flee,olherwlae to deliver to another,carder an the nada to said daalanation,It Is mutually agreed,as to each tarter of all or any of sold property over all or any potion of said route to destination,and as to each party at any time Interested In all or any said pfapedy,than every service to be perfarmed hereunder shall be subject to all the conditions not prohibited by law,whether printed or written,herein contained(as specified In Appendix B to Part 1035)which are gree hereby ad the shipper and accepted for himself and his assigns. This is to certify that the above-named materials are properly classified,described,packaged,marked and labeled and �e in ro er condition for trans ortation accordingto theapplicable regulations of the Department of Trans oifatlon. PER: IPPER: f CARRIER: %” ' 'ta, I^ 61 is PER: - DATE: PER: �T ' 1=2 DATE: /- EMERGENCY RESPONSE MONITORED AT ALL TIMES THE HAZARDOUS MATERIALS IS IN TRANSPORTATION, TELEPHONE NUMBER: ( ) INCLUDING STORAGE INCIDENTAL TO TRANSPORTATION(172.644). — (REV.OW)