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This Memorandum Is an acknowledgment that a Bill of Lading has been Issued and Is not Original Shipper No. Bill of Lading,•rior a copy or duplicate,covering the property named herein,and is Intended solely for filing or record. Carrier No, Date Pegs—�� of (Namol of Carnal {SLAC} 0W271201$ C. i.-gal eh+pmamni Ino rosrero"CO(7`mart appoil oeloro liortionael's name or ea awrwlas provided In tell seen, FROM; TO: Shioper Consignee Street olifee 1100".08 St Street2991 Elliell Louis* Aye City U ii—end aa—e state map Code ®;T!T Citywalftlim StateeA Zip Code 24 hr.Emergency Contact Tel.No. Route Vehicle Number No.of UnitsR n BASIC DESCRIPTION TOTAL QUANTITY WEIGHT CHARGES &Container Type `�`'f UN or NA Number,Proper Shipping Name,Hazard Class,Packing Group (Weight,Volume, (Sul to RATE (For Carrier GalloFie,etc,) Corral Use Only} Acid,Lead),R(ISA),PG11 Propane Cylkirlden PLACARDS TENDERED: YES =i Na I REMIT Nota— t where the rale la dependent on value,eh D.D-D.TO: (1 pe ppen ere squired to state I hereby declare that the=ni or this ADDRESS eAectIcelly In wrttlng the agreed or declared value of the properly,as foNowe:"rhe consignment are fully and accurately agreed or declared value V"property Is hereby specifically staled by the shipper to described above b1'the proper ahoping C O.D.FEE be no:ericeetdng per name and are clasill packaged, C�D Amt: $ PREPAID Q (2)Where tre applicable tariff provisions apacify a limitation of the carriers Iabsent marked and Iahallecimlacarded,and are COD COLLE=CT C3 S a release or a value declaration by the Gripper and the shipper does not release kr ell main proper .concillhn for ~~-J the ear'tore Ilebllly or dedare a value,the rami liability shall be IFnhed to the extant transport according to applicable Subisn to Sli 7 01 the con�tlsna,r this shipment Is to be delivered to the TOTAL prantlad by such prov1alone.Sae Ni 11sm i7p� International and national govammenta; ale ee without mmuni on the consignor,the oonelgnor.hal: sign the CHARGES 8 (3) Cc requiring spade or additional Dare or attantlpn In handling or slowing regulations. Iollu ng statement;- muet be eo marked and packaged as to ensure safe transportation.See Soetlon 2 e of freight camp.hell not eh a delivery m this shipment wahou psyma t o1 FREIQHT CHARQES Po O IraVpht ane all olMrlawlul ohsrpea, hem 390,Bills 01 Lading,f:mIght III antl Statements of Charpea and Section 1(a)of FRElarii IoMil p Cheool Raurpe the contract Tenm a and Cpndlllons for a list of such articles. Sl�natlll'B CaPpt Mien i at �� {Bldrwwre of Cenacnerl nGla re Mocked ❑ RECENEO,subject to the elosilAeatIone ens iirMi In.fled on the dale or the Issue at dile 991 ol Lading, Wall Rn9 Al to each party at any lime InNrebtee In NI Cr any mid nperry,that ovary service to 60 the propo[y described above In apparent good order,ertal as holed:coca a and CMdItlM of can. performed hereunder shall bo sul to III b!a b14 of All lemta 4 gongpon;In Inly govintn g Dial Iotle of cumpeo unknown),married,consigned.and daetineo as Indlmtdd above wri said gamer elrlcation on the data of shipment. (the word Dinner being unaliki thro6i this contract as manning Any person or oarporaifan In ahlrmar hereby aonlgae that he Il laminar vAlh all the 111i Lerma and eondlllons In the poefeealm d the property undo the contrast)agrees to tell to Ib usual place of dnllwry lit now deslF gdvar inp daA9111oallCn and the sold terms and oondaarhe are hereby e01 to by the shipper and netlaa,tl en Ili read,chill w all to another Carrier on the mule Id said da ti lmn II Is ml accepted for hlmil and his aaelena, sly agroad u Io lad"Dal d all or any al,said property over a6 or any Porten of sold mule 10 dell. S ER CARRIER e PER PER f[� 1 DATE Permanent post•offlos address of shipper, se.ue e�..M x STYLE CF375.4 C 2012 LABEL ASTER® al 821.68l www.lebelmaeter.aam