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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 /> 05d h-4 "Lot 11�hklq .("We"enter recipient name)hereby acknowledge receipt <br /> of the following product(s)with the full under4nding of theirorigin(i.e.,partof a damaged package shipment). We <br /> have been advised thatthe 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 /> matehals(s)in accordance with applicable regulations.Upon taking possession of these products)we agree 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 Mems 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)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 /> t U a TYPE OF <br /> z� o a i= CONTAINER <br /> a o �l AMOUNT (Can. box.drurn, <br /> 6 0' a �I ? DESCRIPTION #OF ITEMS (gat.oz.!h,etc) pail,or.) <br /> J �I w M, }-, <br /> C(—� d' O-i – — <br /> bTL <br /> _ --_ f <br /> I <br /> ILL � <br /> # I <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 /> lj(�g0 Sr <br /> Facility Alpha Code/NumbercipientAddress <br /> FedEx Ground Facility Se ana Printed Name Recipient Printed Name <br /> FedEx G ndFacilitySeniorManage Signature Recipient Signature <br /> v727 0 <br /> itDate Date <br /> Reference: Waste Minimization Plan,ENV-702 <br />