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J <br /> r <br /> 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 /> Not Qnly the fa Tity, senior manager can sign this document. <br /> IV IV �e `G ("We"enter recipient name)hereby acknowledge receipt <br /> of the following product(s)with the full understancliAg 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 and purpose.We will properly dispose of empty container(s) or remaining <br /> materials(s)in accordance with applicable regulations.Upon taking possession of these producks)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 eltgibte 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 O VERGOODS. <br /> INSTRUCTIONS: Place an W 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 /> I� HAZARDOUS MATERIAL OR LIMITED OUANTTTY ITEM QUANTITY&TYPE OF CONTAINER <br /> TYPE OF <br /> 0d I CONTAINER <br /> Z_ o <br /> Z z <br /> AMOUNT (can,box,driun, <br /> z o w;l ui,oz,lh,etc.) Pail,etc) <br /> Ji r: DESCRIPTION I #OF ITEMS fs <br /> u a• aw a o <br /> Ql�l LAO <br /> I I I rt;� vi V oo z <br /> l <br /> l <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 0vergoods. 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 /> _FRyVC 191S3 S c I,7, C <br /> Facility Alpha CodelNumberv r Recipint ddress <br /> FedEx Ground Facit ty Sen io Mania erPnnted Name Re ipie�trinted Name <br /> C V � <br /> Fedl Ground FaciIty orManager Signalure RecipientSignature <br /> l U?. 101 , I V <br /> • p e Dat <br /> Reference: Waste Minimization Plan,ENV-702 <br /> i <br />