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9SN 'IN AVSO :6 S10 2 n V aulil paniaaalI� STATE OF GAUIFORDILA "WLFI, DEPARTMENT 101'FOOD .AND AGRtCULTCTRE Meat,Poultry and Egg Safety 13r=ch 1220 N Street - AUG .0 5 2015Manifest No.: Sacramento,CA 95$14 (916)900-5004 ENVIRONMENTAL HEALTH 79-124 �11/12) PERMIT/SERVICES Man:ffest - luedible Kitchen Grease Trazisport Instructions and Receivi g,�aeTty Information . { ''.A complete Ineffible Kitchen z ease )Transport Manifest for a lead of XKG consists of this form and sk geocrator copies from MPESTo1rm 79-125" (Manifest-Inedible Kitchen Grease Transport, " Generator Inform-ation)-for generators that cdntribdte IKG to the load. Alteruativ°eiy,the IKG I transporter may rise other forms that contain all required information. All forms in each manifest must (� 'have the sake Maniest Nuinber. Transpoiters must keep compieted•manifests•for.two years- Manifest Instructions: 1.The driver of the IKG transport vehicle is responsible for entering all information on this form and on MPES Form 79- :125,Manifest-Inedible Mchen Grease l ransport, Generator Informafion,.except fior in the Receiving Facility Representative and Generator Representative name and signature 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 Flow for each load of IKG. Give one copy of the completed form to the receiving - faoi!4 at the time of IKG receipt or mail or definer the copy to- ie receiving facility within 15 workdays- S, Enter the Manifest Number found at the top bf this form in the Man fest No. box.on the generator form(MPES Form 79- 125)for each generator that contributes to the,Ioad. All generator.forms from generators where lKG was collected to t 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 IKG colleotion 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 attaohed genprator forms for two years from the date on this farm. rune of 1KG Receipt used booking oa Date of ItCG'Receipt � Type of ❑ 1 '1 ani PrUr IKG_ ntercepWrlCrap Grease (I IFWc�"rving Fadfity Name_ } #. Receiving f acztifyadd�ess`"' 19 Total Received Gallons Measuring Method used: ContainerVolume'(IfRequired)_ Perwntage Mi(If Required)_ �. ° Li Pounds Recgistered Transporter Name: �, I` 4 Vehicie Decal Number_ _ �` Receiving Faciw Rep live Name(Printed): Driver e{�fiRt�d}: i Driver Signature: Receiving Facility Representative Signature:' c d 196 '°N AVCO :6 SlOZ 'S 'SnV