Document e5dYag1dkyLeD6eygeoOn5MNg

HL-3 Rav. 5-84 STINE-HASKELL REQUEST FOR SHIPPING 3Date. -2 3 TO: \Plant or Company (* a.id. ^ . Lt )Q iL 1C 'Attention U,*Address Ia C^ ('< 1 ^tWiKS 1 '* / .(/ ru>. . .. "V.-hr-sr".. ATSikl ...................... 1 <\}> y Pv.^2'^ City ~>c>e O t bod (L State mT Zip M)(n3 ........................... Phone ( ) Description of Shipment K, V -,r, A T* ">.................. . Chemicai Name i r* A (if applicable) Haskell # Type of inner pkg Total No. of containers MR# Hofon Sample Voiywt. .1(j .0.:.3OP. bA No. of inner pkgs. HAZARDOUS MATERIAL lf]NO DYES (IF YES. COMPLETE CLASSIFICATION BELOW) CHECK HAZARD CLASSIFICATION, ASTERISK SECONDARY CLASSIFICATION (SEE REVERSE SIDE FOR DEFINITIONS) EXPLOSIVES CLASS A P ETIOLOGIC AGENT ORGANIC PEROXIDE RADIOACTIVE MATERIALS (**) POISONOUS GAS, CUSS A . POISONOUS LIQUID, CUSS A FUMMABLE GAS NONFUMMABLE GAS FUMMABLE LIQUID () (BELOW 100F) Bp cp P P P P P a p OXIDIZER .......P FUMMABLE SOLID ... ................ --.......... . a. CORROSIVE MATERIAL (LIQUID) .. p POISONOUS LIQUID, CUSS B p POISONOUS SOLID, CUSS B . CORROSIVE MATERIAL (SOLID) a .p IRRITATING MATERIAL p COMBUSTIBLE LIQUID (*) (BETWEEN 100F& 200) OTHER REGULATED MATERIAL AQ Bp CO DQ EQ CARCINOGEN OSHAp STRONG P ___________ (*) FLASH POINT--TAG. C.C. , _______F. ... (**) SHIPMENT MUST BE APPROVED BY THE RADIOLOGICAL SAFETY OFFICER MATERIALS WHICH COULD POLYMERIZE OR DECOMPOSE IN TRANSIT ARE PROHIBITED Basis for Hazard Classification (References etc.) ______ _____,_________:___ ________ SPECIAL INSTRUCTIONS......{/,,P--gp___ggfe____ --^- - - - - cUtff A . Va-1- - - - - - - -- - - - - - ,- - - - - - - - - - - - - - - - - - - - SIGNED 0 i K {{i ____ ^ CHEMIST/SUPERVISOR BUILDING M-~: j ........... RM EXT. 0 - SJ.L</ REVIEWED & APPROVED TO BE COMPLETED BY COMMITTEE SHIPPING NAME____________________ _ LIMITED QUANTITY YES p. NO p DOT COORDINATOR OR DESIGNATE DUP040002168