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OP-978 <br /> FedEx Ground 01122/2021 <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 /> !-,SQGV2W ("We"enter recipient name)hereby acknowledge receipt <br /> of the following product(s)with the full undbrstanding of their origin(i.e.,part of a damaged package s hipment). We <br /> have been advised thatthe material(s)constitute hazardous substances under federal and state laws and m ust 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 ag ree to fully <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 items)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 /> � <br /> Z TYPE OF <br /> a I CONTAINER <br /> z of <br /> z 0p oc AMOUNT trap.bar,drum, <br /> u�JJ DESCRIPTION #OF ITEMS (gal,m,th,e1r.) pail,e1c,J 1 <br /> I l e BUIL l 't U, e z <br /> CJ �A Z L7Q�i� <br /> iAw <br /> a <br /> h ergIL <br /> I G <br /> O <br /> �-- o -z <br /> `-1 q cls ----- -- a- <br /> - <br /> AMMUNITION NOTE: Only facilities in AK 8 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 /> iDa L f 95_1; �� q (� CA M 5�06kkln Lf� <br /> Facility Alpha CodeAumber Recipient Address <br /> 414 RE k2 12AW (� I64 <br /> FedEx Ground Fa 'itySenior Manager Printed Name Recipient Printed Name <br /> S��g= -- -C�l <br /> Hft im <br /> FedExGround F6litySeniorManage ignature Recipient Signature <br /> _ os - / S - 2-0z --l _ Irglzr _ <br /> Date Date <br /> Reference: Waste Minimization Plan,ENV-702 <br />