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s��r oFCAU?01�, WrON hj9 : __91H_ '9 'Urr III ij pania�3a� DEPARTMENT-OF FaUD AND AGRICULTURE Meat,Poultry and Egg Safety Branch E �} 1220Nstreet Manifest No. Rte— 0s t7 sacrameato,CA 95814 (916)900-5004 ~ 79-124 (Fst.11112) Manffi,-st - Inedible Kitchen Grease Tr-ax-sport Insctib�ns and Receiving-I'ac�ity Infor�a�.at�on �: f. :A complete Tnedi le kitchen r s'se�Q)Transpolrt Manifest for a load of 1KG consists o�thYs forms .and all generator copies from MPESAForm 79-125 (Manifest-Inedible Kitcbterrt Grease Transport, Generator Iinfornoatiou)for generators that contlribflzte)KG to:tbte load. Alternstkve3.y,the IKG transporter may use other forms that contain all required morn a. ion. Am forms in each manifest must {11 ,have the same Manifest Number. Transporters'must keep campleted-&a>aifests for.two years.. Il Manifest Instructions: 1.The driver of the lKG'transport vehicle is responsible for entering all information on this form and on MPES Form 79•- :125,-Manifest-Inedible Kitchen GreaseTfansport, Generator lnformation;.exceptfnr in the Receiving Facility Representative and Generator Representative name and sighalure boxes- All entries must be in ink and legible The driver must initial any correctiormto information already entered. 2. Enter all information in the form below for each load of lK(3- Give one cppy of the completed form to the receiving t -ifacillity at The time of lKG receipt or m it or deliver the copy to 1he receiving facility within-15 workdays- _-3. orkdays-3. Enter the Manifest Number found.at the top bf this form in the Manifest No.box.on the generator form(MPES Form 79- 12�)for each generator that contributes to the load. All generator 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. t ' 4. Give the generator copy(from MPES Form 79-125)to the generator at the time of 1KG collection or mail or deliver the f r copy-to the generator within 45 calendar days_ E 5.Attach the generator forms(MPFFS Form 79-125)for all generators that,contributed to the load of 1KG to this form. �! Maintain this form and the attached generator forms for two years from the date on this form. • I Bate of IKG Receipt �- Time of IKG Receipt Type of r-1 Used Cooking Oil .� J / v G RM 1KG: � Intemeptor/rtap Grease f(� Recenrmg F=TMi Name_ M ; i Receiving FaaTity Ad ,- 1 � ' 7-A or U , Total IKG Recsived: Meaevring Method Used' Corrtainer Volume'(if Required): Percentage FII(If Required)_ Gallons /}' • Ll Pounds /1�� IK;giss!emd Transporter Name: ehic�le Decal Number. - f ti� []mrer Name(Printed); F,ecWrig Facility Papresenta ve Name(prirttia%d): N briva�r pall ReoMting FaaTrty Repmsentative Signature:•L t, a 6 'd H 'ON Ado Z 9102 '9 ur