Document ykyOwymNvKqLExmM04zj8zkoV

HL-3 Rev. 5-84 STINE-HASKELL REQUEST FOR SHIPPING TO; Plant or Company {'_ Attention .. Address 7 7/ ) City Description of Shipment V\v- f` iPc j JkJ. y/ LtXjut ,$/)kr'.r. At T.' .............. C) <7. /. ( sf)) <?-,. State *)'T' TtySltfOl 3} A. /f % Phone tk T4t>.. ?. Chemical Name F) Tr (ifapplicable)Haskell# Type of inner pkg Total No. of containers MR# . Sample VoUwt. /oO-'vjr) / No. of inner pkgs. HAZARDOUS MATERIAL - {IF YES, COMPLETE CLASSIFICATION BELOW) CHECK HAZARD CLASSIFICATION, ASTERISK SECONDARY CLASSIFICATION (SEE REVERSE SIDE FOR DEFINITIONS) EXPLOSIVES CLASS AO B.Q ETIOLOGICAGENT ....... " ` ORGANIC PEROXIDE RADIOACTIVE MATERIALS (**) on ...... OXIDIZER FLAMMABLE SOLID CORROSIVE MATERIAL (LIQUID) POISONOUS LIQUID, CLASS B POISONOUS GAS, CLASS A POISONOUS LIQUID, CLASS A FLAMMABLE GAS NONFLAMMABLE GAS FLAMMABLE LIQUID f) (BELOW 100F) . .. a . POISONOUS SOLID, CLASS B CORROSIVE MATERIAL (SOLID) IRRITATING MATERIAL COMBUSTIBLE LIQUID (*) (BETWEEN 1POF&200P) OTHER REGULATED MATERIAL AQ BQ CD ........... --............ ............................................... --CARCINOGEN OSHAQ STRONG (*) FLASHPOINT--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.) Ui a REVIEWED & APPROVED TO BE COMPLETED BY COMMITTEE SHIPPING NAME LIMITED QUANTITY YES ;Q. NO DOT COORDINATOR OR DESIGNATE DUP040002184