Document wqM64Ek8nrvyv5ZzroQmOD8go

REQUEST FOR SHIPPING TO: Plant or Company CA , l . ? v S Ubl^S Attention , i flOo CLWfijU) i\-JHnc i A/yC > Address TcLo~b*>. 5L<rfc 7ac, $ 7H) City f>c>c x k v A State WT" Description of Shipment -Bkl-P Date **3 Zip tftbb'5 Phone (O&i) Chemical Name Lef!~i> (if applicable) Haskell # Type of inner pkg Total No. of containers, HAZARDOUS MATERIAL MR# IhivO ... . Sample Vol./wt. 4. ...... No. of inner pkgs. YES w.' - .(IF YES, COMPLETE CLASSIFICATION BELOW) CHECK HAZARD CLASSIFICATION, ASTERISK SECONDARY CLASSIFICATION EXPLOSIVES CLASS A ETIOLOGIC AGENT ORGANIC PEROXIDE RADIOACTIVE MATERIALS (**) . POISONOUS GAS, CLASS A 'POISONOUS LIQUID, CLASS A BQ (SEE REVERSE SIDE FOR DEFINITIONS) ... ' CQ; o x id izer ... .........::: .. ...... - FLAMMABLE SOUD..... CORROSIVE MATERIAL (LIQUID) .......... POISONOUS LIQUID, CLASS B ~ Q ::`" POISONOUS SOUD, CLASS B : CORROSIVE MATERIAL (SOLID) ., FLAMMABLE GAS NONFLAMMABLE GAS FLAMMABLE LIQUID (*) (BELOW 100F) IRRITATING MATERIAL COMBUSTIBLE LIQUID (*) (BETWEEN 100F& 200) ....... ' .. OTHER REGULATED MATERIAL AQ BQ CQ DQ EQ CARCINOGEN___OSHAn STRONG n (*) 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 (Referencesetc.)__ _________ _ ..... _________ SPECIAL INiTTRl IQTIONR ' . 'KojLp CTt v X < Ul-Hv \* C^Vi V^iC ^ Q Kfjt c*J C 1(if none Indicate) 3: ~~ Q~V OUUL) JoJ a ----- - ..... ,- _________ SIGNED w v c h Fmis t /s u p e r v is o r BUILDING tt-j "52r m //o'7 f x t . 6 y REVIEWED & APPROVED TO BE COMPLETED BY COMMITTEE SHIPPING NAME____________ LIMITED QUANTITY YESQ . . .. ,, __ ____~ ; ,.", ;;.... --- - ` -- - ~ NOD ______ _ d o t c o o r d in a t o r o r d e s ig n a t e ... .. .,,r: ________ _ _________________ DUP040002174