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0ti98 'IN Wd9ti 0 SIOz 9 ��W I paniaaa� <br /> TATF OF,CA EORMA -� <br /> DRPARTNT OF FOOD AND AGRI�LT�,TURE � <br /> Mead poultry and Egg Safety Srarrcjx <br /> 1220 N Manifest` •N6-- 02—Q <br /> Bnt0,CA 9-581;1 • Q <br /> (916)900-6004 <br /> 79-124 est 11/12) b` <br /> 5, <br /> _. ]vRstrk, Ons and Reee> g:Facifit- In orma ion <br /> )P ed; Iertc en'Grease�IKGa`TransportMfrnifest.for a load of IKG consists of his form <br /> _.�.r.._ <br /> ;ab d all generator copies fx'om MFES--Form.79-x25 (Man�-fn edi Ie Kitc$ezr Grease��ra po <br /> :Generator Inforq�otion)for geaex tors- �oziti�ilite'�G to Weloacl."Afternatrv'ely;theII�G <br /> t�orter imay use other,forms that contain aH required ixifarmatiou- AR forms in each manifest must <br /> ?brave the same i�uest Ncimber.' xnsporters must>�eep;eompTetc >,aaaifesfs for tivo years:Manifest lnstrUetiohs. <br /> 1.The driver of the 1KG transport vehicle is respansble for entering all irlfbffnb on on Transpo this farm and on MPES Form 79- <br /> :125, Manifest-Inedible fCitchen Grease :Generator_lriforrnation,.exwept.for in th Ei ReceMng Facility <br /> _'Representafive and Generator Representative name and sigma re boxes_ All entries must be in ink and legible- The <br /> =driver must,inial any corrections to information alteady_entered <br /> 2. Enter all information in the form below for each load of iKG. Gare one copy of the campie#ed form to the receiving <br /> fact r 121-the'time i f IKG (6wiR or mt11 or'ddiver the copy to'the receiving faaTitq within 15 work d <br /> , ays- <br /> ;3. Enter the Manifest Numberfou d,at.. • <br /> n #i►e.top.'Of this form Yin the{II}an�fest No. box,on the generator form(MPES Form 79- <br /> 125)for each gel7emtor that conftibutes p,tlie,,iaad` AI!g neratorforms from:generators where iKG was collected to t <br /> make up the load must have the same Manifest Number as the attached Receiving Facil"rty Information form- <br /> :4. <br /> am►_•4. Gyve the generator copy(from MPES Form 79--125)to the generator atfhe time of IKG oolleot+on or mall'or deliver the ' <br /> copy.to the generator within 45 calendar days_ <br /> 5.Attach the gene4or forms (MPES Form 79-125)for all generators that contributed to the load of 1KG to this form. <br /> Maintain this form•and-the attachett generator forms fror two years from irhe date on this form. <br /> WfLa of 1KG Rewe t 79ne of KG Receipt:: <br /> Type <br /> of � used Cooking 0i] <br /> ^' AAA PM IKG: rcep2orlrrap <br /> I <br /> Grease <br /> Reaennrtg FamRy Name - - <br /> 27 <br /> Total MIS Received: Meadiring MOW Usdd: CcVr finer Volume'(if equir�: g f R vire <br /> ��Gallons "ParcenSa a Fill{[ eq d)- <br /> �+ <br /> Pounds 33i� , <br /> RegisEered Transporte-N=e: Vehicle Dept Number- <br /> Driver <br /> umberDriver Name(Print; R <br /> ecetvrng Faces Reprpsentaii�e(Primed)coill <br /> Cc <br /> - <br /> / f ti• <br /> G� 2: <br /> Drives Sign rra: Rece- 't�q FadTdy Representative Signature. <br /> - L-t_ hC , <br /> S 'd 89lZ N NVW0l-SIH '9 m <br />