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9566 "N AVSD :6 SI06 'S snd emit paAia:a� sTA.TF_OF CALIPOR1,4LA -^ 1� DEPARTMENT-Ole`FOOD AND AGRICULTURE � Meat,Pouttry and Egg Safoty Bramh (� �,r � 1220 N Stmt Manifest NO:: K- �� J Sa entd,CA 95814 AUG 0 5 2 015 �U (916)900-5004 l 79-124 (E=11/22) EWRONMENTAL HEALTH PE�IT/$ERUI r Man%ffest w Inedible 10tc en rease aiissport - # Instructions and Receivb� -FacWInformation 1 ''-A complete Ix>ted le Kitchen re Se G.-)T'rshsport Manifest for a load of IKG couszsts of this form ,and all generator copies from MPESTorin 79-125 (Manifest-xiutetY.%ble Kitchen Grease Traiaspor4 i Generator Laformatfon)-for generators that cdAtribilte IKG tai the-load. Alternatively,the IKG taansporter may use other forms that contain arequired i formafiion. All formas in each mauffest must J 'have the same Manifest Number. Transporters must keep completed-manifests fox-two yeam Manifest Instructions: 1_The driver of the IKG transport vehicle is responsible for entering all information on this form and on MPES Form 79- .I :125, Manifest•-Inedible K2tchen Grease Transport Generator tnforrnatiori,z.xcept for in the Receiving Faciffty ?� Representative and Generator Representative name and signature boxes. All entries must be in ink and legible. The Ij driver must initial any corrections,to information already enured; t 2.Enter all information in the form below for each load of IKG. Give one copy of the completed form to the receiving facirrty atthe time of 1KG receipt or mail or deriver the copy to-the rec eMng facility vAhin-95-workdays. 3. Enter the Manifest Number found at the top of this form in the Manifest No. box-on the generator form(MPES Form 79- 125)for each generator that wntributes to the,load- All gi~nerator forms from generators where[KG was collected to make:up the lead must have the same Manifest Number as the attached Receiving Facility Information form. 4. Gime the generator copy(from MPES Form 79-125)to the generator at the time of 1KG collection or mail'or deliver the copy to the generator within 45 calendar days_ 5.Attach 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 denfrator forms for two years from the date on this form. Dater of 1KG Receipt Time of lKG Receipt `` U Joking OB' AM EKG: ;I PM lntetCeptodrrap Grease i R&o�h ng Facility Name:I 0<� ", i Receiving Faality Addie "Y 75-1 Total 1KG Received: Measuring Method Used: ContainerVolume'gf Required). Percentage Fill of required): Gallons Pounds33 C/ Regtstarad Transporter Name Vehicle Ducal Number. y Ohver Name Printed): RsaWng Facility Representative Name(Fruited): f! DriverSignahrre: Recti' g Facility ReFntairy nature,' AV20 : 6 -S [H 'S ny1'