Document 7R34evqxKb8XOGZyGeE1Vapze

REQUEST FOR SHIPPING TO: Plant or Company (3^c 3^v k Js u l -.<? Cc_______ . Attention v rV?. C/ l>a-u Address 2ZO Q, CL L ( Kw)____________ City Dgj...ptXbtJg.^.................." State MTV Description of Shipment p.kY?q Sc^v-^pl-P3 Date 13 Zip &Z0Z3 Phone (Jfi) Chemical Name (if applicable) Haskell # Type of inner pkg . ___ - , Total No. of containers--.... v... MR# ?G(/Q ____________ _ Sample Voiywt. J^L^LJu L_____No. of inner pkgs. ------------- - HAZARDOUS MATERIAL ^O,.,..: . QYgSfcsfs^dE'.YES, COMPLETE CLASSIFICATION BELOW) ~7 CHECK HAZARD CLASSIFICATION, ASTERISK SECONDARY CLASSIFICATION (SEE REVERSE SIDE FOR DEFINITIONS) EXPLOSIVES- CLASS AQ BQ ETIOLOGICAGENT "? ; ORGANIC PEROxiDE ' Z - r RADIOACTIVE"MATERIALS ( *) POISONOUS.GAS, CLASS A. POISONOUS LIQUID, CLASSA1.2 FLAMMABLE GAS NONFLAMMABLE GAS . FLAMMABLE LIQUID (*) (BELOW 100F) -cp OXIDIZER ^FLAMMABLE SOLID CORROSIVE MATERIAL (LIQUID) POISONOUS LIQUID, CLASS B .. ... ___ . .POISONOUS SOLID, CLASS B. . . .. - , ; CORROSIVE MATERIAL (SOLID) IRRITATING MATERIAL ..... COMBUSTIBLE LIQUID (*) (BETWEEN 10CTF&200) OTHER REGULATED MATERIAL AO BQ : . .. CQ DO EQ ............. ------------ ------------ --CARCINOGEN H FLASH POINT--TAG^ C.C. I... 2P. C' :-A7 OSHA STRONG (**) SHIPMENT MUST BE APPROVED BYTHE RADIOLOGICAL SAFETY OFFICER . MATERIALS WHICH COULD POLYMERIZE OR DECOMPOSE IN TRANSIT ARE PROHIBITED Basis for. Hazard Classification SPFOIAl INSTRHOTIONR" ^ (TV cK ;------- .. v. ' ^ ^ iA/hi-hc 'beltVe^> (if none indicate) :.... V SIGNED ., CHEMIST/SUPERVISOR <L i RllliniNG * RM !!(/*"[ FYT *- 'SZ'jLl REVIEWED frAPPROVED ^ r -r --r-:' TO BE COMPLETED BY COMMITTEE SHIPPING NAME DOT COORDINATOR OR DESIGNATE ....... i:-~ . DUP040002181