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Is an edgement that a bill of lading has nd Is not THIS MEMORANDUM or duplicate, covering he property named herein,been ndsis fnended solelthe for filling or record, Bill Ing, not arnpy i Shipper's No . Carrier #14 . _ - . - a SCAC Carrier's No. RECEIVED, subject to Individually determined rales or contiads tat have been agreed upon In writing between the carder 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; at date from fF 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 carder 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 : Consignee Shipper Street J ! r• , <; , Street ;> re, i Destination WINa , , , ' Zi Route Delivering Carrier Vehicle Number U . S . DOT Hazmat Reg . No . Number and Type IMMIM IsDo Description of Articles of Packages Number I IBM l/ 7i C 71 , 65 iLFF Remit COD to : - - - Subject o eSection eliv r of conditions,thcon fi this COD FEE • shipment is to be delivered to c the consignee COD AMT. without recourse an the consignor, the Address : consignor shall sign he following statement: Prepaid ❑ The carder shall not make delivery of in City: State : Zip : shipment without payment of freight and all Collect Elother lawful charges. 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 d hereby specifically stated by the shipper to be not exceeding $ Per (signature of consignor) $ ❑ Prepaid ❑ Collect NOTE: Llabi...y Limitation for loss or damage in this shipment may be applicable. See 49 U.S.C. • . 14706 c 1 A and (B)a 11BY SHIPPER BY CARRIER This is to certify that the above-named materials are property classified, described, packaged, marked and labeled, and are In proper condition for transportation according to the applicable regulations of IDRIV!ER'Sthe Department of Transportation. Per E: SHIPPER: ri i , �4- CARRIER : ` I � !1 _ .: . . _ j A PER: / ! �f,• . rl .l DATE : ' / r PER : — DATE : EMERGENCY RESPONSE NAME OR CONTRACT NUMBER TELEPHONE NUMBER : / 6 ' OR OTHER UNIQUE IDENTIFIER : 29-BLS-C3 969 (Rev. 9/10)