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OP-978 <br /> FedEx Ground 05/2812020 <br /> Hazardous Material Donation and Reuse Distribution <br /> Acknowledgment of Receipt <br /> If you need assistance in filling out this form,please contact the Environmental Affairs deAartment, <br /> Note: Only the facility senior manager can sign this document. <br /> �L! tiMA tJr;: ("We enter recipient name) hereby acknowledge receipt <br /> of the following product(s) with the full urAerstanding of their origin (i.e., part of a damaged package shipment). We <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 either a hazardous material or Limited <br /> Quantity/ORM-D.Items not evaluated as a hazardous material or Limited Quantity/ORM-D must be sent to OVERGOODS. <br /> INSTRUCTIONS: Place an Xin 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 /> HAZARDOUS MATERIAL OR LIMITED QUANTITYIORM.'D ITEM QUANTITY&TYPE OF CONTAINER <br /> uj Z TYPE OF <br /> zl o'I 0 CONTAINER <br /> 2 p AMOUNT (carr,box,drum, <br /> 11-i r DESCRIPTION #OF ITEMS (gat.oz,ib.etc.) pail,eMc.) <br /> C7 <br /> f ✓ i —i - - - Yo-z <br /> -fiOCIJ1 <br /> ✓ OYD bi <br /> ✓ IDYt1tiCLA <br /> _ h - Z n 07- <br /> z I <br /> ✓ I I 5 a z CICA-0 <br /> ✓ <br /> AMMUNITION NOrE. Only facilities in AK&NI 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 copy of the <br /> recipient's identification (i.e.badge, license, etc.)to this form and retain a copy for your records. <br /> -FRKC, i q53 Ll 5 ILIO 5 ktk) Octg5Zls <br /> Facility Alpha Code/Number Recipient Address <br /> 6F 01 CA4 i In <br /> FedEx Ground cility Senior nag r Printed Name Re <br /> cipient Printed Name <br /> Ali FedEx Gro Facility enior Vanagif r Signature Recipient Sign ture <br /> / I Z e <br /> Date Date <br /> Reference: Waste Minimization Plan, ENV-702 <br />