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9HO "N Md :Z 9 Z '9 'Ur cold p;Aia�a� STATE OF CALTOI`NLl ?� DE PARTIMMNT OF FOOD AND AGRICULTURE Meat Poultry and Egg Safety Branch 1220 N Street Manifest No:: Sacr=euto,CA 95914 (916)Sao-5004 r 79-124 (Est 11112) Man est 1.tl:dpi 1e K -tchen Grease Trail;-sport on ?, eceivin 'atLili Infornuat ion P ns�rnlc ns and -g t3' A,complete Inedible Kitchen Grea'se ;G)Transport Mamffest for a load of IKG consists of this form ' :,and all geuerstor copies from NIPES SForm.79-125 (Manifest-Ynedible Kitchen Grease Trausport, [ Generator WorIIlatfon)for beiierators that edixtribute IKG td'th.e load. Aiterna"ly,the IKG transporter may use other formas that contain all required informatiion. .All.forms in each,manifest must � "have the ssme Manifest Nimber. Transpoirters•must keep compl6ted•fanniifests for-two years. _ r Manifest Instructions: �I 1..The driver of the lKG transport vehicle is responsible for entering all information on this form and on MPES Fonn 79- ;1 125, Manifest-Inedible Kitchen GreaseTranspork Generator Infb"ation,•except for in the Receiving Facility � Representative and Generator Representative name and signature boxes. Ail entries must be in ink and legible- The ] driver must initial any corrections.to information already entered: 2. Enter all informaton in the form below for each load of lKG. Give one copy of the completed form to the receiving faciCdy atthe time of 1KG receipt or email or deriver the copyto-the receiving facility within-l5 work.days. 3�. �i 3_ Enter the Manifest Number found at the top bf this form in the Manifest No.box.on the generator form(MPES Form 79- "125)for each generator that cAntributes to the Load. All genera-Eor.forms-from generators where 1KG was collected to make up the load must have the same Manifest Number as the attached Receiving Facility information form. ' 4. Give thepY tor eneraco (from MPES Form 79-125)to the generator at the time of lKG collection or mail or deliver the g copy to the generator within 45 calendar days. _ 5-Attach the generator forms (MPES Form 79-925)for all generators that contributed to the load of IKG to this form. Maintain this form and the attached generator forms fortwo years from the date on this form. � • I »of IKG Receipt: Time of IKG Receipt Used Cooking Oil T�� Grease IKG_ ,-f ��-;.�.� - r—.. � �• � 1 ,� � ,qM PM Int rcee�ptorlTrap Receiving Facl ty Name: Receiving FaalityAddn m "-- r rr li Total lKG Received: Menng Method Used Container Volume(lf Required): Percentage Fill(if REquired):Gallons � .-�- c e � Pounds Registered Transporter Name: Vehicle Decal Number. r larzre>rNarne RecEiving Facirdy ReNa presentative m4(Printed)-. dr Drier Signature: f2ece- i�g FaaGiy Representative Signature-' �? 'd �flti •CN AdK:: 9lH .9 'U�r