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- Oti98 '°N Wd9ti :Ol SIOZ '9 'ASW ;wil paAi ;);a <br /> STATS OF r'-ALIFORNIA _ — — <br /> DEP-I R NT OF FOOD AND AGRICULTURE � �1 <br /> Meat,Poaluy and Egg safety7rarecfl Manifest No:: <br /> i2,-)o N street <br /> Sacramento,CA 95814 <br /> (916)900-5004 <br /> 79-124 (Est.11(12) <br /> Manifest - Inedible Kitchen Grease Transporty � } <br /> Instruedons and Reeewmi g-FaeTty Infoxmation <br /> =.A complete Inedible Kitchen, r e- G)Transport Msnirfest for a load of IKG consists of this form � <br /> ,and all generator copies from MPES Torm 79-125 (Manifest-Inedible Kitchen Grease Transport, <br /> Generator Worm'ation)for generators that e6i tribitte UKG to the,load. Alternatively,the 1KG � <br /> transporter may use other founts that contain.all required inform�afion. All forms in each manifest must <br /> have the same Manifest Number. Transporters'must keep complet,ed•manffests for-two years. <br /> Manifest Instructions: <br /> 1.The driver of the IKG transport vehicle is responsible for entering all information on this form and on MPES Form 79- 1. <br /> :125, Manifest-Inedible Kitchen Grease Transport, Generator lnfonnation,.except for in the Receiving Facility �. <br /> Representative and Generator Representative name and signature boxes- All entries must be in ink and legible_ The <br /> driver must initial any corrections,to information already entered; F <br /> 2. Enter all information in the form below for each load of lKG_ Give one copy of the completed form to the receiving <br /> facility at the time of IKG rec,�ipt or mail or definer the copy to the receiving#acidly withinIS workdays- <br /> :3. Enter the Manifest Number found at the top:of this form in the Manifest No. box.on the generator form(MPES Form 79- "1� <br /> 125)for each generator that contributes to the load. All generator forms from generators where IKG was collected to <br /> make up the load must have the same Manifest Number as the attached Receiving Facility Information form. <br /> from MPF_S Form 79•-125)to the generator at the time of IKG collection or mail or deliver the <br /> 4.Give the generator copy( i <br /> copy to the generator within 45 calendar days. <br /> 5.Attach the generator forms(MPES Form 79-125)for all generators that contributed to the load of IKG to this form. j <br /> Maintain this form and the attached generator forms for two years from the date on this form. I <br /> Time of IKG Receipt: Used Cocking 4i! <br /> Date of lKG ipt -type of ❑ s <br /> ✓�'7 / �" � � fqM� PM IKG- interoeptorfrrap Grease <br /> Receiving Faeirrty Name_ - r <br /> Receiving Facility Addnss:"—"y / I• <br /> Dial IKG Received_ Measuring Method Used, Container Volume'pf required): . Percentage Fill(if Required)_ <br /> f�Gailons <br /> N <br /> ' ❑ Pounds 1� r Gf� � <br /> Registered Transporter Name Vehicle Decal Nu[m[�er. / <br /> 2 <br /> D&er N3rne(Printed): I�epenring Facal'rty RepCesentairve Name(P ) i <br /> J� <br /> brivr~r5igna#ure: R -iv cil'rty Reprasentatnre Signature:' <br /> C d c9lZ '�N Wd6ti Ol SIOZ 9 ��W r <br />