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THIS MEMORANDUM or4ZIlangtheaprpt,"nbtwa w':' dand;d;o"fwMn;rMill COML noa`°p Shipper's No. Carrier SCAC Carrier's No. RECEIVED,subject to Individually determined rates or contracts that 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 the Properly described below,in apparent good order,except as noted(contents and oondition 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)agroos to carry to delivery at said destination,d on its route,or otherwise to deliver to another Garner on the route to said destination.h is mutually agreed as to each carrier of ail or any of said Property over all or any portion of said roule 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 Gofrditiens on the back hereof,which are hereby agreed to by the shipper and accepted for himself and his assigns. TO: FROM: Consignee Shipper Street Street Destination Zip Ori in Zi Route Delivering Carrier Vehicle Number U.S. DOT Hazmat Reg. No. Number and Type —7H,,,rd Pkg Total Quantity I WcicJht Class or FIM Description of Articles (nubject to -ty-) or correction) of Packages Number Class Grp. Ictiov! Rate Remit COD to: subject to Section 7 of eondkl one.if this ///�� shipment hdelivered to the consignee 1 _OD AMT: COD FEE. withoutrywree coo urss e an the consignor, the v Address: censirshall sign the Following slaLemenl L+ The carder shall not make delivery o1 this Prepaid ❑ City: State: Zip: shipment withoul payment of Irawfight and al! $ Collect El$r' other laul 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 Q@ hereby specifically stated by the shipper to be not exceeding $ Per (signature of consignor) $ ❑ Prepaid ❑Collect NOTE:Ueblitty Limitation for lose or damage In this shipment may be applicable.See 49 U.S.C. 147 cAl A end B. VAN R- BY SHIPPER ❑BY CARRIER This is to certify that the above-named matenals are properly classified,described,packaged,marked and labeled,and are in proper condition for transportation according to the applicable regulations of • s rDRIVERIS the Department of Transportation. Per URE: SHIPPER: CARRIER: PER: DATE: PER: DATE: EMERGENCY RESPONSE NAME OR CONTRACT NUMBER TELEPHONE NUMBER: OR OTHER UNIQUE IDENTIFIER: 29-BLS-C3 969(Rev.9110)