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OP-978 <br /> FedEx Ground 0112212021 <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 /> c' Q e ("We"enter recipient name)hereby acknowledge recei pt <br /> of the following product(s)with the full understarAing of their origin(i.e.,part of a damaged package s hipment). 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 remai In ng <br /> materials(s)in accordance with applicable regulations.Upon taking possession of these product(s)we ag ree to fu Ily <br /> release and indemnify FedEx Ground Package System, Inc.("Fed Ex 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. Items not evaluated as a hazardous material or Limited Quantity 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. Keep a copy for your records and a copy for the recipient. <br /> HAZARDOUS MATERIAL OR LIMITED QUANTITY ITEM QUANTITY&TYPE OF CONTAINER <br /> c TYPEOF <br /> al ;=I - I CONTAINER <br /> zl 0j 0j 0 W AMOUNT (cwn, hor,drum, <br /> r= I X DESCRIPTION sl #OF ITEMS (gal.nz,1h,etc.) pail,e1c.} <br /> dl_�_ <br /> — I <br /> N29 55 <br /> iL�� las /115 <br /> IA Cir oo ,� _Z b <br /> l , c-0 1 <br /> iL <br /> AMMUNITION NOTE: Qnly facilities in AK 8 Hl are to donate ammunitrT 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 retards. <br /> T- A c i g 5 3 -` 9D <br /> Facility Alpha CodelNumber ReGiipiientA dress <br /> — <br /> FedE Gro d Facillt agerPrinled Name 7 <br /> _ R ient Printed Name <br /> ::a�! .— <br /> Fe axGyroucilitySe ior Manager Ob cipient Signature <br /> `1.57,;sz/ <br /> Z-1 <br /> Date Date <br /> Reference: Waste Minimization Plan,ENV-702 <br />