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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 /> ("We"enter recipient name)hereby acknowledge receipt <br /> of the following product(s)with the full u—nd6rstAnding 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 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 evaivated 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 tem(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 /> Z TYPE OF <br /> xo <br /> a. ~ CONTAINER <br /> oAMOUNT lean, box.drum, <br /> J Q wi X DESCRIPTION #OF ITEM$ (gal,u_,!h,e1 c.) pail,e1c.) <br /> U Q a Q o <br /> loanc <br /> bqB- a u2yjQ (A4_ <br /> IAIIAJ)p I)r WE 0-Z' <br /> 00- 07- 'Otiffe <br /> L <br /> _144_. <br /> L oz 6 <br /> AMMUNITION NOTE: Only facilities in AK& Hl are to donate ammunition to authorized enforcement agencies. All other facifities <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 /> 126 <br /> � I qS - - q '0 # vuy �� S n, c <br /> Facility Alpha Code/Number ; Recipient ddress <br /> Fed,Ex Ground Facility Senior ana erPnnt d Name Recipient Print amp <br /> FedEx Gro ndFacility Senior Ma agerSignature Recipient911 <br /> ature <br /> l� X0,9 4mj� _ <br /> � 2 <br /> Date Date <br /> Reference: Waste Minimization Plan, ENV-702 <br />