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OP-978 <br /> 0512812020 <br /> FedEx Ground <br /> Hazardous Material Donation and Reuse Distribution <br /> Acknowledgment of Receipt <br /> If you need assistance in filling out this form. please contact the Environments!Affairs department. <br /> Note: Only the facility senior manager can sign this document. <br /> �j (Ve" enter recipient name) hereby acknowledge receipt <br /> of the following productb <br /> s) with the full understanding of their origin (i.e.. part of a damaged package shipment). e <br /> have been advised that the material(s) constitute hazardous substances under federal and state laws and must be <br /> used in accordance with its intended use end purpose. We will properly dispose of empty container(s) or remaining <br /> materials(s) in accordance with applicable regulations. Upon taking possession of these product(s) we agree to fully <br /> release and indemnify FedEx Ground Package System, Inc. ("FedEx Ground")from any liability arising from the use of <br /> these materials(s)excluding tax liability. <br /> Product(s) received: <br /> IMPORTANT: An eligible donation or reuse distribution is items that have been evaluated as eithera hazardous material or Limited <br /> Quantity/ORM-D. Items not evaluated as a hazardous material or Limited Quantify/ORM-D must be sent to OVERGOODS. <br /> INSTRUCTIONS: Place an 'X'in the category and include a description for each container donated for reuse distribution. Be sure to <br /> indicate whether the item(s) is/are hazardous material or Limited Quantity/ORM-D. Keep a copy for your records and a copy for the <br /> recipient. <br /> rr HAZARDOUS MATERIAL OR LiMITED QUANTITYiORM-D ITEM QUANTITY &TYPE OF CONTAINER <br /> TYPE OF <br /> 0 o' CONTAINER <br /> Z o z AMOUNT (can,box,dntnt, <br /> a O W � u°Ci DESCRIPTION #OF ITEMS (gal,oz.Ib,eic.) pail,etc.) <br /> x <br /> U, C a a o <br /> L j LPA/ rjt� �i� 2PkS <br /> sOct _ Lrtd <br /> O <br /> U 2 <br /> Olt <br /> v <br /> AMMUNITION NOTE: Only facilities in AK&1-11 are to donate ammunition to authorized enforcement agencies. All other facilities <br /> must send their ammunition to Overgoods. If you are one of the facilities that are authorized to donate, attach a opY f e <br /> recipient's identification(i.e. badge,license, eic.J to this form and retain a copy for yo rrecords.y 5't O 5. W��� <br /> C 1 3 "� �.1, (W e SUL1 t4 STIm ,C <br /> Facility Alpha Code/Number Recipient Address <br /> &Ground <br /> GSSG �� e„t <br /> F i r Manager nted Name R ipient Printed Name <br /> FedS nior ger Signature Recipient Signature <br /> 40OLI Z/ <br /> [late <br /> date <br /> Reference: Waste Minimization Plan, ENV-702 <br />