TM 10-6640-239-13
HAZARDOUS MATERIAL SHIPPING PAPER
page 3 of 3
To:
consignee
From:
shipper
Street:
Street:
City:
Zip:
City:
Zip:
Phone #:
Phone #:
Delivering Carrier:
Vehicle#:
U.S. DOT HazMat Reg. #:
Qty
UNIT
SIZE
HM
Shipping Description (Shipping name, Hazard Class, ID #,
Packing Group)
Total
Amount
Labels
5
2.25 oz
Paste, Gasoline Indicating
11.25 oz
5
3 oz
Paste, Water Indicating
15 oz
2
1 gal.
X
Petroleum Distillates, n.o.s, 3, UN1268, III {Dry Cleaning Solvent}
2 gallons
Flammable
Liquid
13
4 L
X
Petroleum Distillates, n.o.s., 3, UN1268, II {Petroleum Ether}
52 liters
Flammable
Liquid
2
500
grams
Potassium Phosphate, Dibasic
1000 grams
1
500
grams
Potassium Phosphate, Monobasic
500 grams
6
1 lb. cyl
X
Propane, 2.1, UN1978
6 lbs.
Flammable Gas
1
500
grams
Pumice, Technical
500 grams
2
2.5 kg
Silica Gel
5 kg
2
1 lb
Silicon Carbide
2 lb.
1
1 kg.
Sodium Carbonate, Decahydrate
1 kg
1
500
grams
X
Sodium Hydroxide, solid, 8, UN1823, II
500 grams
Corrosive
1
500
grams
Sodium Sulfate, anhydrous
500 grams
7
2.5 L
X
Sulphuric acid, 8, UN1830, II
17.5 liters
Corrosive
1
20 L
X
Toluene, 3, UN1294, II
20 L
Flammable
Liquid
This is to certify that the above named materials are properly classified, described, packaged, marked
and labeled, and are in proper condition for transportation according to the applicable regulations of the
Department of Transportation.
Signed:______________________________________________ Date: ___________
EMERGENCY CONTACT: ____________________________________
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