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6titi8 '°N Md:ti SIOZ ady aUJI J paA1 0 <br /> STATEU. ORNIA <br /> DEPAR'T'MENT QF FOOD AND AGRICULTURE <br /> Meat,Poultry and Egg,Safety Branch <br /> I:2oNstreet Mani€est No;: <br /> &qento,Cry 95$I4 I <br /> (916)900-5004 <br /> 79-124 (F$t I1/12) <br /> Max>�i�fest edible-� c e' Grease ' C x IIsp►oa +t <br /> Instruettons and ReeeiL � <br /> vag F'aciity -Inforivation r E <br /> . ryr • „ - p <br /> A complete edi"Ihle liaitchen� xease G) I'ir las-Port Manifest.fora load of I.KG consists of this form <br /> ;and all generator copies froinNI PESAForm 79-125 (Manifest-Inedible Kitchen Grease Tr'anspo'rt, <br /> Generator Iafornlatzaln)for ge,66 atot-t]Y;iF col;tribute JKG to iLh.'e'load.'Ajter na*ely,:the 1 KG, <br /> transportelr may use Other forms that contain all required Wormation- A 1 forms in each,manifest must <br /> !have the same�anilest Number. '�ransportets mast deep<colmpleleTlloaaniifests f'bfliwo 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- <br /> :125, Manifest Inedible Kitchen Grease"1_ranspo.M Generator-information,except.for in the Receiving Facility <br /> :Representative and Generator Representative name and'sig'rraWre boxes. All entries must be in ink and legible. The <br /> driver must.inMal.any correcfrorns to information already,,entered <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 /> fad llty at the fiffie cif[KG receipt or mail or'deliver the copy tothe receiving-ftidi iy within-X15,work,days:• <br /> t th # <br /> 3. Enter the Manifest Number found ae, o Qf this€orrrrnFin#}te Manf <br /> P„ est No. box,pn the generator form(MPES Form 79-- <br /> 125.)for each generator that contl;itMes to the,Toad' All generator forms from generators where IKG was collected to # <br /> make up the Ioad must have the same Manifest Number as the attached ReceMng Facilit' 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 <br /> capy_to the generator within 45 calendar days_ <br /> &Attach the genes-4tor forms(MPES Form 79-125)for all generators that contributed to the load of 1KG to this form. 17 <br /> Maintain this farm'and,the attached generator forms for two years from the date on this,form. ,i <br /> Late of IKG Receipt: �+ Time of 1KG receipt; T of r I Used coo(dng OR1! <br /> //:57 <br /> 7i"^?M IKG: �'1rrter��eptor/Trap Grease � <br /> RecbMng>=acTrty Name: <br /> Receiving FaaTifyAdrf '_'"-'".� <br /> Total IKG Received: MEasu'ring Metii a Used: GSstainervolume'(lf� equiredy - Pe=ntage f=ill(if Required):�allons ' <br /> Pounds 0 <br /> Pegisfemd Transporter-Nam <br /> Vehicle Decal Number.' a <br /> Driver Name(Printed): RewMng Fadi y Reprr,—,ertative Name(Point <br /> 00 ) <br /> RriverSignature= Receiving Faa� eptesent2tive Signa re: <br /> Ol 'd=M [ '°N— b', ., <br />