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6titi8 "N WdBti Z SIOZ 'adV awil pania)ay . S7XyyA; 7L�.iyFyO-+E21;1IA y��r�* 7-� •�7y� �77�7� r�+{�y -•• " �1!EPART.1'`e r NT VA' A'0_0D AND,.�GA'IC Ul:l UhFi .� 7 lvle4 poultry and E,P; tt Safety Branch ]G_ � s .1220 N Street Manifest NO.. Sacramento,CA 95814 (916)900-5004 79-124 (Est 11!12) 1V� qua est ned bile�itc�,en,G ease"I ra'nspoi Instrubns andeeeavax "FacInformation f � '•A complete 7n dx'bIe Kitchen'Grease )Tir>a"toisport Manifest,for a load of 1 KG eo�usists of this form ,and all generator copies front-AWRS'Vorm 79-125(Mau fest-Inedible]Kitchen Grease Tranvoi* :Generator ba£oirniation)for gelaeraturs t1fafcohtrib te'JKG to th'e'load.'Alternatively;the W-G, transporter may use other farms that contain all required irnforma#olu_ AM forms in- each manifest must 'have the same " r xt festNu�abel� Tzansparters must Deep c�mplete&-ianifests fofIOo pears_, Mani€est Instructions: 1. The driver of the IKG transport vehicle is responsibte for entering all information on this farm and on MPES Form 79- 125, Manifest-inedible-Kitchen Grease Transport; Generator•information, except,for in the Receiving Facility , I .'Repnasentative and Generator Representative name and signage boxes. All entries must be in ink and legible_ The � driver must,initiai"any corrections to information almady_entpred I j2. Enter all information in the form below for each load of lKG_ Give one copy of the completed form to the receiving '1 facift 'at'the tune b'f[KG receipt or rriail or'deliver the'copy to the receiving-facirdy wlihirt°9 5"work;days_- 0.1 3. Enter the Manifest Number found at thertop Qf this form in the Manifest No. b&'po t the generator form(MPES Form 79- ) -126)for each generator that contributes to the.,toad. Alf gefierator Farms from ger±et'ators where IKG was collected to i f make up the load must have the same 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 lKG collection or mail-or deliver the t copy to the gt✓nerator within 45 calendar days_ 5.Attach the generator forms (MPES Form 79-125)for all generators that contributed to the load of iKG to this form. Maintain this farm and-the attached generator forms for two years from the date on this,form. 1 Date of IKG Receipt" Time of 11 heceip> TYF�P Used Coolting Ort P �( AM PM IKG: rZ,r Irrtarceptarfrrap Grease C Receniing FadfAy Name: Receiving FacTwLy'Addre�" x' 71 r �a Total IKG Received- Gallons Measuring Method Used= 'Cdrittftiner V me'(If l equir4: percentage Fiv(if Required): Pounds Registered Transporter Name: Vetaicte Decal Number: :a, ,_Ss , 7 Driver Name(Printed): Receiving Fadrrty Representative dame(Printed): Driver Signatu Race aTdy Representit vve Signature: add .