Document daxQ7o1evJgVKY9Mv1pypK18B

REQUEST FOR SHIPPING _ Date__`. 7 r (O TO: Plant or Company Attention Address J (! fYl? Q .Wo-l ________ ______ / <XM .'So fvr.C .A-OvC i /?~i >->. ?C ?' <~ l~ j City D'- vo cL>f_______ Description of Shipment T5> ; <^rl State ' "-f: 1 Ni~T______ __ Zip QWj t j Sry< Phone ( Chemical Name j -rr-tci - (ifapplicable)Haskell# - -- . -.. Type of inner pkg ~r - . _ - ...... .................................. .. MR# c)i^LO __________________ . ~Sample Vnl/wt. ICC ` -^Cr\ L Qf jnner pkgg. Totai No. of containers------------------------------------ ,3 JsV HAZARDOUS MATERIAL J^NO s.-^YES :lj;. ..(IF YES, COMPLETE CLASSIFICATION BELOW) CHECK HAZARD CLASSIFICATION, ASTERISK SECONDARY CLASSIFICATION (SEE REVERSE SIDE FOR DEFINITIONS) - CD O EXPLOSIVES ' . CLASS A ETIOLOGIC AGENT ORGANIC PEROXIDE RADIOACTIVE MATERIALS (**) POISONOUSGAS.CLASSA POISONOUS LIQUID,:OASS A -' OXIDIZER ..___,_____ ... .............. FLAMMABLE SOLID CORROSIVE MATERIAL (LIQUID) POISONOUS LIQUID, CLASS B .... ------ ....... . POISONOUS SOLID, CLASS B : CORROSIVE MATERIAL (SOLID) . ' -- i o o... . FLAMMABLE GAS NONFLAMMABLE GAS " ~-r FLAMMABLE.LIQUID (*) (BELOW 100F) IRRITATING MATERIAL o COMBUSTIBLE LIQUID (*) a (BETWEEN 100F & 200) a. OTHER REGULATED MATERIAL AO BO CQ DO EO (*) FLASH ROINTr--TAG. C.C., CARCINOGEN F. .......... . OSHAD STRONG O 7. - ..... ; ......... (") SHIPMENT MUST BE APPROVED BY THE RADIOLOGICAL SAFETY OFFICER . . MATERIALS WHICH COULD POLYMERIZE OR DECOMPOSE IN TRANSIT ARE PROHIBITED Basis for.Hazard Classification (Referencesetc.)___________ ..... .... ....___________ ____ ^.__ ,--------- SPECIAL INSTRUCTIONS. {ls a ? &> (# none indicate) SIGNED 77? ij CHEMIST/SUPERVISOR REVIEWED & APPROVED: TOSECOMPLETED BY COMMITTEE SHIPPING NAME ______________ LIMITED QUANTITY YES NO .BUILDING. :r m. !f"'7 f EXT- POT COORDINATOR OR DESIGNATE - - - DUP040002157