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titi62 "N MS : Z S -0 -unr awil p9A1 0 STATE OF CALIFORNIA _ li DEpARTMarENr Op'ooA AND A G Tc�uLTURF, Meat,Poultry and Egg Safety Branch �; Y' _ � Manifest No.-: Q. 0 6 0. /1 1?20 N Street ' - aor,awntoCA 95$14 S� , - PY (916)904-5004 Co 79-124 (Est.11/12) „z.�.�,. Manifest - Inedible kitchen Grease Transport _ (� g iiity Information � 1 Instit-uons and Receivila�Tac. . .. - 'A,complete Inedible Kitchen.6rea'se G:)Transport Nbmffest for a load of 1KG consists of this form and all generator copies from WESTorm 79-125 (Manifest-Tu edible Kitchen Grease Transport, � Generator Wormatifon)for generators that eoiitribUte JKG to the'load. Alternatively,the IKG transporter may use other forms that contain all required information. All forms in each manifest must 'have the same M.anitest Number. Transporter s'must keep completed•mai6 fests for.tw•o years. f Manifest Instructions: 1_The driver of the IKG transport vehicle is responsible for entering all information on this form and on MPES Form 79- lI except for in the Receiving Facility :125, Manifest-Inedible Kitchen Grease Transport, Generator'Information; Representative and Generator Represeniative 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 below for each load of IKG. Give one copy of the completed form to the receiving facility at the time of IKG rect jpt or mail or deliver the copy to-the receiving fac+lity within-15 work.days_ l 3. Enter the Manifest Number found at the tap bf this form in the Manifest No,box.on the generator form(MPES f=orm 79- 125)for each generator that contributes to the load. All generator forms,from generators where IKG,was collected to make up theload must have the same Manifest Number as the attached Receiving Facility Information farm. from MPES Form 79-125)to the generator at the time of IKG collection or mail or deiiver the 4. Give the generator copy( f copy to the generator within 45 calendar days_ S.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 generator forms for two years from the date an this form. l Date of lKG Receipt: Time of IKG Receipt: -r of ❑ Used Oil Cooking O PM l L.� Intereeptorfrrap Grease 1 Receiving F e lity me: f Receiving Faca"Gty Address`_--'— "l ted,' Total IKG Received- Measuring Method Used: container olume'(lf Required): Pementage Fffl(lf Required)_ ' ❑ Pounds f t � (` Vehide Decei Number_ Registered Transporter.Name: Driver Name(Printed): Receiving FaaCdy Representative Name(Printed): Driver Signature: Recti ing Fadl'rty Represent2t3ve Signatu Ile 9 d=«tiz 'ON Wd« :z 5[H '0[ 'ung ,