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OP-979 <br /> FedEx Ground 01M12021 <br /> Hazardous Material Donation and Reuse Distribution <br /> 00410101 <br /> It you need assistance in filling out this form, please confad!ha EnVitO 111 Wal Aff2ir dl?paftm2r�t. <br /> Note: Only the facildy senior manager can sign this document. <br /> ("We"enter recipient name)hereby acknowledge receipt <br /> of the following product(s)with the full understanding4 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 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 accordancewith applicable regulations.Upon taking possession of these product(s)we ag ree 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 eligibfe 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 dem(s)Ware hazardous material or Limited Quantity Keep a copy for your records and a copy for the recipient. <br /> HAZARDOUS MATERIAL OR LIMITED QUANTi'TY ITEM QUANTITY&TYPE OF CONTAINER Ij <br /> __._ - TYPE OF <br /> ca r J o CONTAINER,'. <br /> a <br /> 2 n o AMOUNT (oan,aor.art„n.l <br /> o ”' #OF ITEMS (ga;.u.,lh,e1c.) paid,etc.) <br /> w ' w 1- DESCRIPTION <br /> t� d a ¢ o <br /> L to <br /> AMMUNITION NOTE: Only facilities in AK&Hl are to donate ammunition to authorized enforcement agencies- Ail 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 /> TRA c 1 ab 3 !A�ao c k as 3tocx-ko�\ CA 1,51e <br /> Facility Alpha CodeiNumher Recipient Address <br /> FedEx Ground Facility Sen' agerPnntedName Recipient Printed Name <br /> –� =:;, — 4k%W <br /> FedEx Grou d Facility Senior Ma er signature Recipient Signature <br /> 06 - 07 - Z.Ozt <br /> Date Date <br /> Reference: Waste Minimization Plan,ENV-702 <br />