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OP-978 <br /> FedEx Ground W2812020 <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 department. <br /> Note: Only the facility senior manager can sign this document. <br /> Del-6 aA — ("We" enter recipient name) hereby acknowledge receipt <br /> of the following product(s) with the full urjerstanding 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 /> M TYPE OF <br /> Z o z � CONTAINER <br /> re o AMOUNT (carr,box,drum, <br /> ca UJ <br /> jX U4 F DESCRIPTION #OF ITEMS (gat,oz,lb,etc.) pail,etc.) <br /> v a a a o <br /> GO- <br /> I Fr,Pr- <br /> C <br /> I _ <br /> AMMUNITION NOTE: Only facilities in AK&HI 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 /> Facility Alpha Code/Number Recipient Address *5Z 5 <br /> �l <br /> 7-Qound Fac"ty Senior Hager P6nte Name /] Recipient Printea Name <br /> ed Ex Ground cility nior M Hager S' ure Recipient Signature <br /> 0 <br /> Date Date <br /> Reference: Waste Minimization Plan, ENV-702 <br />