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titiWON MES : Z S 0 ung awil p;Aiauay STAT:OF r a1 TFMt DEPARTMENT OF FOOD AND AGRICULTURE Meat,Poultry and Egg Safety B=ch 12.20 N Street Manifest No:. Sacramento,CA 95814 y (916)900-5004 ti r 79-124 (list 11/12) iy �0 P Manffest -�1u( atchen- -&ASe Transport oo Instradibns and Recewmi g-Facphy Information 0136 'A complete xued>I�Xe kitchen Presse 0IIL )Tramport Manifest for a load of 1�G coaas�ists o f tbrs dorm and all generator copies from MPES Torm 79-125 (Manifest-Iuedi6le Kitchen Grease Transport, Generator Information)for,enerato>r-s that c6Atribdte IKG to the load- .A,lternaiavely,the IKG a transporter may use other forms that contain ail required information. AIl forms in each mauifest must 'brave the saute Manifest Number. Tr=sporters'must lip compie>ted•ivaiffest&for-two years. Manifest Instructions: ;1 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 1-achen Grease Transport, Generator Information,apt for in the Receiving Facility ?i Representative and Generator Representative name and signature boxes. All entries must be in ink and legible. The !' driver must initial any correc ions.to information already enured; 2. Enter all information in the form below for each load of IKG. Give one copy of the completed form to the receiving faciidy at the time of IKG receipt.or mail or deliver the copy to-the receiving facility within I Er workdays. 3. I=nter the Manifest Number found at t1 ie top bf this farm in the Manifest No. box-on the generator form(MPES Form 79- 125)for each generator that contributes to the load. All generator forms from generators where I KG was collected to make up the load must have the same Manifest Number as the attached Receiving Facility Information form_ 4 4. Give the generator copy(from MPES Form 79-125)to the generator at the time of IKG 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 denerator forms for two years from the date on this form. - - i Date of I1CG ipt Time of t1CC�Reeoipi T of 0 Used Cooking bel � ype i._t f �'" Ar 1 M� IKG: #ercep#orfrrap Grease f RLceftd ng FaaTrty Namd- ! f -CjL I —�Lry OrL i- I Receiving Fsoslity dmsP9- etal IKG Received: MeasAiting Method Used: Container Volume'(lf Required): percentage Flt(If Required): R�alians 00 Pounds Registered Transporter Name: Vehicle Decal Number. 7 Priver Name(Printed): Deceiving Facility Representa&e Name(Printed): - I Drives Sign Recd"-ng Facli ky Representative Signature:' rll X 4ON7-7ff'dLLtiZ W�LS Z -SIOZ Ol 'unr t