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STATE 07FCALUORMA - 96Z0 °N-M96 : Z -ML -9 'u�r-Dodi P;A I ;3 y DEPARTMENT SOF FOOD AND AGRICULTURE , l� Meat,Poultry and Egg Safety B=cb 1220 N Street 4Manifest No.: 0'%'57`I Sacramelrto,CA 95814 (9I6)900-5004 n 79424 (Est 11112) Manifest - Inedi]A Kitchen Grease Tran-spox-t Instrule#ions and Reeeiviug•Faec ity Information �- 'A complete baed%le Mtcheiitreq'.se VK �' nsport Manifest for a load of TKG consists of this form. and all generator copies from MPES Worm 79-12a(Maxufest-Inedible Kitchen Grease Transport, j Generator Information)for generators that cdnt>i Wte IKG to:the•load. Alternatively,the IKG , transporter may use other formes that contain aIl required iinforma#on. All forms m each;lmainzfest must F 'have the same Manifest N iQbnbex_ Trranspoiters'xaust keep eompleted-Thaiiifests,fof.two years.. Manifest Instructions: 1.The driver of the IKG transport vehicle is responsible for entering all information on this form and on MPES Form 79- 125, Manifest-Inedible KAchen Grease Transport, Generator Information,.except fear in the Receiving Facility Representative and Generator Representative name and signature boxes. Ail entries must be in ink and legible. The !� driver roust initial any corrections,to information already entered; l 2. Enter all information in the form below for each load of IKG. Give one Copy of the completed farm to the receiving facility at the time of IKG recbipt or mail or deliver the copy to-the receiving facility within 15 workdays_ 3.Enter the Manifest Number found at the top taf this forrn in the Manifest No_box.on the generator form(MPES Form 79- -125)for each generator that contributes to the load. All generator forms from generators where lKG was collected to make up the load must have the sarne Manifest Number as the attached Receiving Facility Information form_ ¢ 4_Give the generator copy(from MPES Form 79-125)to the generator at the time of IKG collection or mail or deliver the f copy to the generatorwithin 45 calendar days. j 5.Attach the generator forms (MPES Form 7.9-125)for all generators that.contributed to the load of IKG to this form_ 1 Maintain this form and the attached ;generator forms for two years from the date on this form. - � I Date of lKG Receipt Time of IKG Receipt �- Type of Q Used Cooking Oil i /J A�A M . IKG: E] intermptoirrrap Grease R&uWving Facility Name: 51 CA. P.ece4ving Faality Adm"�`-'"' Total lKG`Recsnred:' Ga[Eons Measuring Method Used: Container Volume'(lf Required): I Percentage FII(IfRequirecR_ l5- P ounds 1 � Registered Transporter Name: Vehide Decal Number_ Driver Name(Printed): rinted): Receiving Facility Representative Name(Printed): _ DtiverSignatare; / Reoevitg FMaFity Re esertBtive Si nature: d' CZ / 7: L 'd � lti 'ON Md :� 9tH '9 'u�r