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0. 9H 'ON Nd9ti: 01 S10Z '9 �N ;W1.j pania�a�, <br /> �7, ATK~CALffORM, - <br /> DRPARTIIHWT OF FOOD AND AGRZCULTURE - <br /> Meat,Ponitry and Egg Safety Branch <br /> 1220 N Streexr :�: M$IIIE'S -No.: —Q7 ! 1 <br /> Sacramento,CA 95814 <br /> (9167 900-5004 r ' <br /> 79-124 (Est I I/12) µ GOPY- Al", ,I <br /> McllF.l�#'S'l�-��� .` . -., c.r.n•Z:-,:i;4•. . . _ . <br /> �i�e.= �cIe>�:`�>s`�a.�e•"�`r�ric�ol� _ �: <br /> Instrudons and Reeeiv �`aci3ity'Information � 0 <br /> �A CQWp1ete Tned!b1e KQtche»._re2se M�g,)Tiausport Manifest.for a load of MG consists of this form <br /> :and a generator copies trona[MPES Form 79-K2S(Manifest-Knedible Kitchen Grease Trainsport, <br /> ':Generator Udo- fiatidii foie geijaators°thdfEcazitjjb7ut'e'KKG to*' ue hind:'Ait}eraa"ly;the II _ <br /> "nsporter may use other forms that contain all arequ-tred information- An forms in each a .,,ffest must <br /> !have i&'sante Wiest 1;T Jier."'trauspoarters must keep::campleieT-*Am ifests fox.t*o years: <br /> Manifest Instructjohs: l <br /> .1.The driver of the!KG transport vehicle is rtrsponsible far entering aII-infarma6' an this form and on NIPES Form 79- <br /> 125, Manifest-lnedible{Ktchen Grease Transport-Generator-Iriformation,,except_for in the.ReceKAng Facility <br /> :Repmesentative and Generator Representative name and si�r*re boxes. All entries must be in ink end Iegibie. The E <br /> =driver must initial.any corrections to informetion already-entered; _ <br /> �12. Enter all information in the form below for each load of IKG. Give one copy of the completed farm to the receiving <br /> :1 <br /> fadMity at'fhe time aTIKG receipt or mail ordeliverthe-copy to•the receWmg-facil4withink'15"work-days.- .� <br /> ir• <br /> 3. Enter the Manifest Number found,at the,toRa�f this form in the ManVest No. box,on the generator form(MPES Foml 79- <br /> 125.)for each generator that cortributes#p tfi . oad.' All ggnerator forms from.genet fors where lICG was collectedto ' <br /> make up the load must have the same Manifest Number as the attached Receiving Facility'information form_ ' <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 1! <br /> copy to the generator within 45 calendar days. <br /> 5.Attach the generator forms (M1PES Form 79-125)for all generators that contributed to the load of 1KG to this form- <br /> Maintain this form and1he athched generator forms fvrtwo years from the date on thh;-,form. <br /> 17ar�of 1KG Receipt Time of IKG Receipt <br /> Type of Used Coakir,g Oil , <br /> ItCG �lntereaptorlrraP Grnzse I <br /> Receiving Fara-gy Name <br /> ReCehfing FaaTiLy-Addreud=""-'^' a <br /> Total IM Received: Measeirmg Method Wdd: "Container Vol (lf Requires: ' Percentage Fill Of Required)_ <br /> �Gal _1 <br /> lonS <br /> Pounds �' r <br /> Registered Tmnsportertvam Vet»de Decal Number: <br /> 1 Act- <br /> DriverG <br /> J Name(Printed}: ' Receiving Facility Rg�presentaWe Name(Printed): i! <br /> Driver re_ h, Re � ing Facility Representative Signature: <br /> 'd 91 N 098 : 1 SlH '9 'APN <br />