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titi68 'ON Wd�S : Z Sl0Z -0 [ 'unr aUuil P9AI ;); <br /> STATE.OF CALIF &Mh <br /> DF,PARTMENr-OF FOOD AND AGRICULTURE <br /> meait�Poul"and l zz safety'Braneb <br /> Manifest NO:: <br /> 1220 N street <br /> Sammiento,CA 95814 <br /> (916)900-5004 T <br /> 79-I24 (est 11/12) <br /> Manifest - Inedible Wtchen Grease Tran-sport - a <br /> and Recei ' 'FaeT Information <br /> justru+ buS v1n� . . ty <br /> =A complete Inedible Kitchen!fix ease i�IIs Transport Mangest for a load of IKG consists of this fox-in I <br /> :and all generator copies Brom MPES Torm.79-125(MamHest-Inedible Kitchen Grease Transport, <br /> Generator Wormation)for generators'&at tZAtrn"bute IKG to the load. Alternatively,the DOG , <br /> tialaspoarfer may use other forms that contain all required information.. AX forms in each m=ffest must <br /> have the same Merest Number. Tramporterimust keep completed manifests fvr.tiwo years- <br /> Manifest Instructions: ;! <br /> 1.The driver of the IKG transport vehicle is responsible for entering ail information on this form and on MPES Form 79- <br /> 125,Manifest-•inedible Kitchen Grease Transport, Generator information,axmpt for in the Receiving Facility <br /> Representative and Generator Representative name and signature boxes. All entries must be in ink and legible. The 4 <br /> driver must initial any corrections.to informiat!on already entered; i <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 /> facIray at to time of!KG reot ipt or mail or deliver the copy to'the receiving facility within-15 workdays. r <br /> 3. Enter the Manifest Number found at the top bf this form in the Manifest No_box.on the generator form(MPES Form 79- <br /> 125)for each generator that wnt ibutes to the load. All generator forms fnom generators where IKG was collected to <br /> make up the load must have.the same Manifest Number as the attached Receiving Facility information form. i <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 /> t. <br /> copy to the generator vAthin 45 calendar days. _ E <br /> 5.Attach the generator forms (MPES Form 79-125)for all generators that contributed to the load of 1KG to this form_ <br /> Maintain this form and the attached gengratorforms for two years from the date on this form. E <br /> • 1 <br /> Date of lK(3 Receipt Tune of IKG Receipt Used Cooking Oil <br /> Type of <br /> f AM PM. IKG: Intarmptorlrsap Grease <br /> Receiving Facirdy Name. l <br /> Receiving 1=aa7Ky Address;•"_;."" �-s <br /> Measurin Method Used: Container Volume'(If Required): Percentage Fig(If Required}: <br /> Total 1KG Received: Gallons C 9 <br /> c� r <br /> _ 7- / � Pounds v�i-(� <br /> Bred Tmnsporter.Name: Vehicle Decal Number_ <br /> V-o�0 <br /> Qrivel Mame(Printed?: Receiving F*dW Representative Name(Pring: I <br /> �1 <br /> ai <br /> t5river Sig n re-- Race" ng Facility Rapresentaii+r Signature:' E <br /> 6 'd'LLti6 'ON t WdCS Z SI0Z 0 [ 'unr <br />