Document 3x5yRZy2zOpOGK2G4n3bN526

REQUEST FOR SHIPPING natfl Q-2H-X5. TO: Plant or Company Attention (V}? OJeaJL-j / Rex'/ Ss\~CL.A)Sfc I Address ~tbsC&SrO/S) Lc l }O City . ' Description of Shipment \rJr-if4 5cx-/vw-p1 CLr 2.20 State N X" Zip 01?D23. __________ . ............................... Phone7 ............ Chemical Name t-PrvV_______________________________ __ (if applicable) Haskell #________MR# ___________ Type of inner pkg ' _________ ________ ______ Sample VoUwt. No. of inner pkgs. Total No. of containers ________ , HAZARDOUS, MATERIAL ; El NO . YES " (IF YES, COMPLETE CLASSIFICATION BELOW) 7 ''' .............. CHECK HAZARD CLASSIFICATION, ASTERISK SECONDARY CLASSIFICATION (SEE REVERSE SIDE FOR DEFINITIONS) EXPLOSIVES CLASS A P ETIOLOGIC AGENT ORGANIC PEROXIDE RADIOACTIVE MATERIALS (**) POISONOUS GAS, CLASS A POISONOUS LIQUID, CLASS A , FLAMMABLE GAS NONFLAMMABLE GAS FLAMMABLE LIQUID (*) (BELOW 100"F) ... Bp cp P P P P. P P. P. P OXIDIZER FLAMMABLE SOLID CORROSIVE MATERIAL (LIQUID) P O P POISONOUS LIQUID, CLASS B P POISONOUS SOLID, CLASS B CORROSIVE MATERIAL (SOLID) . p IRRITATING MATERIAL P COMBUSTIBLE LIQUID (*) . (BETWEEN 10CTF& 200) OTHER REGULATED MATERIAL AQ Bp Cp Dp Ep (*)FLASHPOINT-^TAG.C.C. Z____ CARCINOGEN ' F- OSHAp STRONG P . ... "Z (**) SHIPMENT MUST BE APPROVED BY THE RADIOLOGICAL SAFETY OFFICER MATERIALS WHICH COULD POLYMERIZE OR DECOMPOSE IN TRANSIT ARE PROHIBITED Basis for Hazard Classification s p f d ia i in s t r iirrnnNs CT^ CML ft~i vCv 1 ON 'C f (OMf* l><?h (if none indicate) j) v SIGNED \j ____ i CHEMIST/SUPERVISOR BUILDING /'M .....RM :l^O ~7 FXT. & S-cP b ; REVIEWED & APPROVED TO,BE.COMPLETED BY COMMITTEE SHIPPING NAME LIMITED QUANTITY YESp - / NOP ______,__ ___ -..................: _______________ __ _________ _____--------- DOT COORDINATOR OR DESIGNATE . . \ ___ . ......-----------,----- ------------ -' ` DUP040b02301