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SHFIN AVSE : H SIH '0l 'gaj aWIi paniaaa� DEPARTMENT OF FOOD AND A.GRIC'ULTURE Meat,POUItry and Egg Safety Branch 1?20 N Street Manifest'Nd.,-' O:; _ F, Sacramento,CA 9581 (9167900-5004 ' 79-124 (EsL 11/12) Manifest-' edible I tcliext G_ ease '�'r-. � ail sport l� Instructions and ReeqPl 'F`aq�i Information 'A complete Inedible Vit4e>1iV644 G Tosport Maaifest.fox a load of IKG consists ol'this form ,,and all generator copies frox�,MF`ES Form 79-I25(Ma;44 st-inedible Kitchen Grease Trausport, ' :Generator 11iforniati&1),far gezierators-t f"cofffiibut+e 1KG to the°lo'acL-,Alternatively,.the-WC,, E 'transporter may use other forms that contain all regydred information. AU,forms in each=n=est must shave the same az est Nximber. Transporters must kip caznplete �loriariilests f6etwo years. Y p 1 f Mani esit Ins'tr'uctiohs: F _1-The driver of the IKG transport vehicle is responsible for'entering all infonmtion on this form and an MPES Form 79- t 5, Manifest-Inedible Mfchen Grease Transport;-Generator-Inform-ation, except.for in the Deceiving Facility ;Representative and Generator Represen6tiV6 name and sig'naaire boxes. All entries must be in ink and legible_ The 'driver must initial,any corrections to information alteady.erti<er edt �l ,,2. Enter all information in the form below for Oath load of IKG. Give one copy of the completed form to the receiving tact btllhe tin ie b-f'[KG Ceo6i"t or mail or'deliver the-co to the recemin -facir v�ithin 16�work_,d Y p, PY 9 �Y 1 3. Enter the Manifest Number found,at the-tobf this form in the Manifest fVo. box;on the generator form(MPES Form 79- 125)for eachenerator that:co tri ut ' 9 t� b es;�o tl�e,,load.'All g�rte,rator farms from where IKG was collected to make up the load must have the same Manifest Number as the attaciied Receiving Facility Information form. 4. Give the generator copy(from MPES Form 7-q-125)to the generator at the time of IKG Golleciaon or mail-or deliver the ! copy to the genera#or within 45 calendar days 5_Attach the gener4tor farms(MPES Form 79-125)for all generators that contributed to the load of IKG to finis form_ Maintain this form and fhe attached generator forms for two years from the date an this,form. Date of MIS Receipt Time of IKG Receipt t _ Used Cooking Oil {� /� f rYPe � / i/ o � PM IKG InteroeptorfFrap Grease Rgi*—irng Facility Name: Receiviru�Faca'Gty-Address�""""x' - {7 - i t. Total IKG Received: Meas"wring Metfiacl Used: Requioad)f Percentage Fill(if Required): j.j Gallons Pounds e,_4"4 b Registered Transporter Name, Vehicle Decal Number_ f;�tc2 � Driver Name(Printed): Receiving F�cirdy Represenbtive Name(Panted): DriverSignature: Receivi 'FacTdyRepresentativ ignatvre: r Sl d=9C01 'ONlWSlOZ 0l gag .