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6titi •IN &d� :Z - SIOZ 'Z 'ady ;Wli paniaDad <br /> 9AT .WCAUFORNIA <br /> DEPA.RTN NT OF FOOD AN"D AG•RICULT"URE <br /> Meat,Poultry and Egg Safety$ranch <br /> 12-10 N suet Manifest No:: R 1�1`(D Z <br /> Sacramento,CA 95814 <br /> (916)900-5004 <br /> 79-124 (Est 1If12) � <br /> 1 ajoiile; tM -Tuedzble�.�iit hen.Gi'* 'I-ra°ns ort . <br /> ] ) <br /> Instructions and Reeei Yaci- it Information <br /> f ��.:, .•.: Y1_ 1. <br /> A complete Inedi�)Ie itches Grease P)Tinnsport] fest.for a load of 1KG consists of this form <br /> :and all generator copies fro MITES'Foxm 79-125 GN1anxfest-inedibleVitchen Grease Transport, <br /> -Generator Information)foir geueii-ators-t1faf'contritiidtIKG to the°la'a7L-Alternatrv- Iy',.the)KG, <br /> transporter mai'use other forms that contain,all required information. All forms iu each malffest must <br /> nave the same tVlanifest Nux�ube� Transporters inuust deep;co�itpleemanifests or.fiio years: <br /> Maniffest lnstiruGtions: <br /> 1_The driver of the IKG transport vehicle is responsible far entering all information on this form and on MPES Form 79- � <br /> _'1,2-5 Manifest-Inedblef`When Grease Trans Generator Information,exce for in the Receiving Facility <br /> ,Representatnre and Generator Representative narne and�sig:64ture boxes. All entries must be in ink and legible. The a <br /> -'drover must,inipal-any corrections to informaiian a[ready.,entered; <br /> ,,2. Enter all information in the form below for each load of IKG. Give one copy of the completed form to the receiving P. <br /> facil�y'at fhe tilde of'IKG receipt or mall or'delnre r the copy to the receiving 1facilrty within 15-�work_.days.° r• <br /> s 3. Enter the Manifest Number found at the,topi�f this form in the Manifest No. box,on the generator form (MPES Form 79� <br /> 125)for each geaerator that contriputes to tf�e!load.',All generator forms-from generators where IKG was collected to <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 coliectlon or mail'or delrver the <br /> copy to the genemtol within 45 calendar days_ <br /> i <br /> 5_Attach the generator forms (MPES Form 79-125)for all generators that contributed to the load of lKG to this form. <br /> Maintain this form and-the attacher[generator forms for two years from the dake on this farm. 1 <br /> a <br /> Da#a of lKG Recent Time of IKG Receipt Used Cooking Oil <br /> //` � Type� � r <br /> �_ r J r - s - <br /> . •- .—/ - .� PM IKG: 1rrtEr�ptorlrrap Grease i <br /> Recenring Fab*Name: ' <br /> i <br /> Receiving FaaTrd t Ad&ess�" <br /> Total IKG Received: Measuring Metfiba Used: co iher Volume' f R ui '} <br /> �Gallans � eq red): ' Percentage Fi[I pfRequired): f <br /> a1' <br /> ❑ Pounds � <br /> Registered TransporterName Vehicle Decal Number. a <br /> cl& o ; <br /> 74 <br /> ririver Name(Printed): Rece n cir <br /> `[tY Represerrtaiive Name(E'rinted): <br /> DrrverSignakumReceivin ci7�•1Re <br /> � ' P�•sentative Signa#ure: <br /> d= z6� 'ON - — M99 :Z _S [H z ady <br />