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1206 "N Md :1 SIOZ -6 'lnr aulil PaAiana� <br /> STATE OF CA7.WORRIA -- ! <br /> DEl?AkTMENT OF FOOD AND AGPJCULTUPJE IT <br /> Mead Poultry and Egg Safety Branch <br /> 1220 N i�� <br /> Street nifest No:: (n " <br /> Sacramento,CA 95814 <br /> (916)900-5004 'r <br /> 79-17.4 fEst.17112) <br /> Manifest - Inedible Kitchen Grease Transport � <br /> Instructions and Receiving-Kaeility Information <br /> A complete Iue&ble Kitchen brea's G)Transport Manifest for a load of IKG consists of this form T <br /> .And all generator copies from MPD+S Torm 79-125(Manifest-1nedilble Kitchen Grease Transport, <br /> Generator Information)for generators that WAtribiillte IKG to the load. Alternatively,,the IKG � <br /> transporter may nse other forms that contain all required information. All farms in each mauffest must I <br /> 'have the same A anifest Numbor. Transpox'ters'must keep completedrmanifests•fo-k-tWo years. <br /> Manifest lrtstrgctions: . <br /> I� <br /> 1.The driver of the IKG transport vehicle is responsible for entering all information on this form and on MPES Form 79- H <br /> 125, Manifest-Inedible KAchen Grease Transport; Generator Inf5ormation,.a:xcept for in the Receinring Facility <br /> Representative and Generatdr Representative name and signature boxes. All entries must be in ink and legible- The ! <br /> driver must initial any corrections.to.information already entered; <br /> 2. Enter all information in the form below for each load of IKG. Give one copy of the completed form to the receiving <br /> facifrty at the time of IKG receipt or mail or deliver the copy to-the rec aiving facility within-15 workdays. <br /> �i <br /> 3. Enter the Manifest Number found at the top of this form in the Manifest No. box,on the generator form(MPES Form 79- <br /> for each generator that contributes to the Ioad. All generator forms.frpm generators where IKG was collected to <br /> make up the load must have the same Manifest Number as the attached Receiving Facility Information form_ <br /> 4. Give the generator copy(from MPES Form 79-125)to the generator at the time of IKG collection or mail or deliver the � <br /> copy to the generator within 45 calendar days. ! <br /> 5-Attach the generator forms (MPES Form 79-125)for aII generators that conuibuted to the load of IKG to this form- <br /> Maintain this form and the attached Generator forms for two years from the date on this form. <br /> Date of RSG Recei Time of IKG Receipt � <br /> pt: Used Cooking Oil <br /> f Type of ❑ i 1 <br /> PM IKG_ mterceptorrrrap Grease ;f <br /> CJ / 1 <br /> Recenring Facirrty Name: <br /> Receiving Fatrl-ity Addrmz " — <br /> i <br /> Th ell, <br /> Total 1KG Raceived: Measuring Method Used: Container Volume'(If Required): Percentage Fill(!f Required): <br /> 1lons <br /> Pounds <br /> Registered Transporter Name: Vehicle becal Number- <br /> s -2� <br /> Driver Name(Printed): Receiving Facility Representative Name(Printed: <br /> [DriverSigna�re Receiving Facility Representative Signature_' <br /> �I <br /> 9 d= ZILl 'ON Wd51 Z -SIOZ ln� , <br />