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I HIS MEMORANDUM Id On acknowledgement that a bill of Iodine has been Issued and to not the Original Bill of Lading, nora copy or duplicate, covering the Property memo bander and Is Intended solely for filing or remord. SHIPPER NO. <br />CARRIER NO. <br />fz <br />ir <br />oARRIER DATE 7� I' <br />TO 'FROM SCAC <br />CONSIGNEE SHIPPER <br />STREET <br />STREET <br />DESTINATION STATE ZIP �:J'Imotwi% Cie', A-vUe <br />ORIGIN YATE ZIP <br />IOUTEVEHICLE1- DOT HazMat Reg. No. <br />r <br />fgpmbet and Type TplahQuanlAy Wetght"' <br />oFPnotp as pe$CrlpilAflOfArttCJeS r (masstia}ume (sUbjecltb Classl <br />.,....r <br />lemit COD to: snhmcl to earlier; 7 m canamcae, If In C®® FEE: <br />shipment Is to be delivered to the consigneeCOD AM <br />a�address: r rol reroUma an the confiner, the remanda IVI <br />shairka the following safersanc <br />me aaraer sbml not make adroay et This Prepaid ❑ <br />State: Zip: shipmenl.mhonpymommheigM ane ah nmer Collect ❑$ <br />TOTE: Where the rale is tle dent on value, 5hi lawlal rna,gea, <br />pen peers are required 10 state specifically In wilting the TOTAL CHARGES: <br />grsed or declared value of the property. The agreed or declared value of the property Is hereby FREIGHT CHARGES <br />comfically elated by the shipper to be not exceeding$ Per ro;,,...,,_..,,,- Ck <br />dhrerlo eneNorcenter on the mule to sale deslinelon. it ism- utuap"""ra••rxa,�.,,,U,w,p�;anan n, passesaon. er me prepaM1y unciae the contract) odder <br />evica to be pedortned hereunder shell ba subject to all the wnpillo sAgreed <br />1pmhibltetl by lecemwhetheor ri pdnlany <br />d otr vrdaenhe/einover <br />wnfalnad, Indutling uie mnd�iolne on the Leek harca(StMicl <br />519ns, <br />UTE: Liability Limttetioh for loss or damage In this shipment maybe applicable. See 49 U.S.C. 14706(c)(1)(A) and (a), <br />his is to certify that the above-named materials are properly classified, described, packaged, marked, and labeled, and <br />a in proper condition for transportation according to the applicable regulations of the Department of Transportation PER: <br />NIPPER:a""• <br />�`-"��';=.. e.��a°`f `��o,B CARRIER: 1%4`m,,.1`.v f�/„ <br />5R: / '.r 4/7 .. 1. PER: <br />p DATE: <br />tif'F i" GA VENC,V E=BF.St7t3NSE f*1:r5fiHL. dtS, d,orgj ffof f,1 f119>Jirs(�t% <br />LLLR"CiONE NiJfCdtirn: Oil OTHV411 UN11013 II)t==L?'HHE-u= l <br />,BLC-03 12267 (Rev. 9/10) <br />acted in all or any <br />to LY Ina shipper end e <br />