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9H6 'CN WVSO :6 S1O� 'S '2nV ;W1j panian;y STA-MO'rCALIFOR11r4 _- RECEIVED --- 1� DEPART OF FOOD AND O' AGRICULTURE - – — Fo� asa iGli AUG 0 5 20 13 Manifest. No:: MO N street Saai=ento,G.R. 95814 ENVIRONMENTAL HEALTH (916)900-5004 PERMIWSERVICES F 75-24 (Esc 11112) Manif-est - Inedible Kitchen Grease Transport . fnstmcdons and Receiving-Fac#i Information r � _A complete Inedible Kitchen�rea'se flKG)Transport ML mifest for a load of JKG consists of this form ;and aU generator copies from MPES-Form 79-125 (Manifest-Inedible Kitchen Grease Transport, Generator Worm-afion.)'for generators that cdittribiite 1KG to the•load. .A.lternatiively, the XKG , transporter may use other forms that contain ail.required information- All forms in each,manifest must 'ha-ve the same A nifest Number. 'Trawporter .must keep completed- aa-1 gists for-two year& � Manifest instructions: ' { • ij 1.The driver of the IKG transport vehicle is responsible for entering all information on this form and on MPES Form 79- :125, 9-_125, Manifest-Inedible Iritchen Grease Transport, Generator Inforrnation,.except'for in the Receiving Facility I� Representative and Generator Representative name and sign ature boxes. All entries must be in ink and legible. The !� driver must initial any corrections.to information already entered: „ r 2. Enter all information in the form below for each load of IKG. Give one copy of the completed form to the receiving , facirrty at the time of I KG receipt or mail or deliver the copy to-the receiving facility within-15,workdays- -3. orkdays- =3. Enter the Manifest Number found at the top-bf this form in the Manifest.No.boxon the generator form(MPES Form 79- , 125)for each generator that wntKibutes to the joad. All generator farms,from generators where IKG was collected to make up the lead must have the same Manifest Number as the attached Receiving Facility Information form. 4. Give the generator copy(from MPES Form 79-125)to the generator at the time of iKG collection or mail or deliver the � copy to the generator within 45 calendar days. ' 5.A#tach the generator forms (MPES Form 79-125)for all generators that contributed to the load of IKG to this form. Maintain this form and the attached generator farms for two years from the date on this form. I - 1 Dale of IKG Receipt Time of 1KG Receipt Type used Cooking Oil i AM 'PM IKG: �Interceptor/Trap Grease .`} i Receiving Fac;rdy Name: f Recah4ng Fa—Rf- Addie -- r Total IKG Received_ Measuring Method Used: Container VolUme'(If Required), Percentage Fill(If Required): Gallons �� f': - t""I Pounds El_I Ix-16 �. Registered Transporter Name: Vehicle Decal Number. Y) a /6 giver Name(Printed): Recdmng Facjlity Repre-err#ative Name(Prhftd). Driver Signature: Reuiiving, acs' R ntaWe Signature.' i 020 : 6 —S l H 'S '2ny,.