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9S76 "N AVSD :6 5107 'S '2nV ;nail P;AI ;3;� STAT c -or CA Y�4PNL% RECEIVED j DEPARTMMNI-T of FOOD AND AGRICIJLTLTRE � Meat Poultry and Egg Safety Branch 12220N Street AUG 0 5 206anifest No:: Sacr=ento,CA 95814 ' (916)900-5004 EWRONMENTAL HEALTH 79_124 OEm 11/12) PERMIT/SERVICES �f- 1V axxff- st - Inedible Mtcheit Grease TraUsport Ynstruelfions and Receiyij�g-l"aci Information- � V Y i 'A complete InedffiIe Krtche re e OTKG)Transport Manffest for a load of IKG consists of this form ,:,and all generator copies from MFESTorm 79-125(Manifest-Inedible Kitchen Grease Transport, � Genex-atolr Uforaiation)'for generators that tWitaiirbizte XKG to the•load. Alternatively,the 7KG transporter may use other forms that contain aIl required information. AIl forms iu each manifest must � 'have the same Manifest Nan ber. Transpoi-tcxs'must keep completed-fn= fests fox•.two years. Mani€est instructions: - - - 1.The driver of the IKG transport vehicle is responsible for entering all information on this form and on MPES Form 79- �l .125, Manifest-Inedible Kitchen Grease Transport; Generator information,.except for in the Receiving Facility Representative and Generator Representative name and signalure boxes. All entries must be in ink and legible_ The !� driver must initial any corrections,to information already entered; _2. Enter all information in the form below for each load of IKG. Give one copy of the completed form to the receiving ' facility attha time of IKG receipt or mail or deriver the copy tothe receiving facility within 1EY workdays. t 3. Enter the Manifest Number found at the top bf this form in the Manifest No, box-on the generator forma (MPES Form 79- :126) 9-`125)for each generator that contributes to the,load. Ail generator forms from generators where IKG was.collected to make up the load 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 1KG collection or mail or deliver the f copy to tl,e generator within 45 calendar days. 5.Attach the generator forms (MPES Form 75--125)for all generators that contributed to the load of 1KG to this form_ Maintain this form and the attached generator forms fortwo.yeam from the date on this form. ., 1 - l Date of IKG Receipt Time of IKG Receipt� Type of dL2 Useking oil--- i. P� iKG: lnlermptorlTrdp Grease ReQeivutg PadW Name: _ Receiving a=aaT Address_"'„' iN kcm' l ImFF-eceived: ,--, ra Measuring Method Used: ContainerVolume'(If Required): Percentage Mill(IfRequiretr): Pounds Regrsteted Transporter Name: Vehide Decal Number- Driver umberDriver Flame(Printed): P6o6 og Facility Popr'2sentaffve Name(Prtrrted): ! pmrer ;gnature Recer"Gn Pari rF Y Represenfalive Signature:' _ t I 6 d-1967 'ONS' - "V// N U4 : 6 _SlOZ 'S �nV