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t <br /> tiIrArr ( n c :Al,n ctilvli; _ <br /> Wit <br /> JUf y )X.(n Ia)j&M.l2 f ) 'n a !ia, r�2 9,q ¢I —r�l ! rL:' ,tIt.. <br /> i ` lYL , a <br /> Ivical , Poultry and Ego Safety )trancll <br /> i ?7.( 1 fel ( <br /> 11 S <br /> Strccl <br /> ilerallleCAlltU , � 95814l it � . i3rl !'! 2 �'.` (:� L <br /> (1916) 9f)U 5( IOrl <br /> n <br /> t u 0, t;f' i11l � t :al':1 r' i� 13 v3Z'S? R ",;'; 9J ' <br /> Complete forms , starling at hoilot Lnter IVtEutifesl INIMoher from WIPES Fortr) 79 1 `Ld for the load . Provide generator with copy at little <br /> of grease collection or deliver to generator kwilhin 45 days . Attach completed copies to wIPF-S Form 79- 124 . 1 <br /> 'Mate: Time : PtWI—�ivianife;;t IJumher. i <br /> d <br /> tG msrator flame: - <br /> , Genorator Addrnss: <br /> iTolal IKG Colloottl t�f — la1leasuring 1:4ethod Used : -- -- - - -- Used Cnuicing Oil t <br /> t, ld`I Gallon:: <br /> Type of i <br /> ! ElPcunds IKG: <br /> mathematical Interoeptor(IYap Urease <br /> Container Capacity (If Flequirnd): Perrentage f=ill (it flequired) : iKG Authorized Recoivinc} Facility Marne: ` <br /> Regional Wastewater Cantroi _ --_' <br /> jam ,porter Name: Generator nepresentalive Name (Print) : <br /> Do A . Parrish and Sons Inc:. j <br /> yDriver Sic)nalurl _ Generator Representative Siyrtature: <br /> k <br /> . . . . .... ..... .......... ... .. .... .. .. . ... . . .. .............. ................. .. . .. .. ... ......, . .......... ..... , ..-.. . ....... .... ... ., ,...., .. . ,.., .. , ...... .. ...... .... .... ............. .... .. - a.:....t . OA.Aavallbi- <br /> A. <br /> it)tltfllnlo* <br /> �)antrc.,,r fvmthc.r. <br /> r <br /> 1Goneralor blame : -- — -- <br /> ' <br /> 3 I <br /> iGonr ralor ' tddiv • • <br /> A <br /> Taldi IIfG Collected : P,feasurinAl ivletharl Used . <br /> Gallons 1 l.yi) u of F1 Used ( oohing Oil <br /> Pounds1 <br /> mc'athematlCal Interceptor% i'rap Grease — f <br /> Crott�uner <br /> G(rill (it Requim(l) : Porconlagow Fill (II flequiretl) MG Aulhorized Hcceiviny Facility Mame: - — — — <br /> � , Wastewater Re tonal Control <br /> Transpdrier (Jame: Generator R .pr entalivc lAAlamr' (Pnitl) -- — --- - - <br /> D . A . Parrish and Sons Inc ._ _ <br /> - - - = <br /> f 1 t j reA <br /> { Genes ttor Representalivc Si <br /> e <br /> .. ...... .. . ... ... .... .. ..... .... ......... . ...... ... .. ..... .._. . ... ..... .. ... ........ . . . .... . . ... . . . .. .. .. <br /> .,., - <br /> (T<ttl3 <br /> t u <br /> ! 1 Time: <br /> !\iv <br /> LT ntil Number: <br /> Generator Nallm : - - - -- — — -- --{ <br /> Gnneralor Address: - - -- — ----- <br /> �1total IKG Collected: !� — Measuring Method Used: <br /> Gallons --_— -- -- � Used ( oolcing Oil — --s <br /> I <br /> Type of <br /> Pounds IItG: &I Interceptor/ IUrc ase s <br /> I. _mathematical _ <br /> lConlainer Opacity (if Ilequired) : Perconiage Fill (II Required) : IKG Aulhodnd F1rre)v)n( Facility b)alne : - -- <br /> t <br /> Re ional Wastewater _Control <br /> t -f'ransporter Name: Generator nepresentalive: blame (Print) : <br /> D . AParrish and Sons Inc . <br /> ( Drivor Signalure: -- - - Generator Reprosenlalive Siynahue: -- --y-- ------ <br /> G <br /> ` 3 i' <br />