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S208 '°N AVSD : ll SlH '0l ,pj ;Wli pania°;� <br /> sr_zx�•.a.F-calxrotuala - <br /> + 'AR' 1V I11'I'OF FOOD Ar1Z3 A ItXCU�.'I[IRaE - <br /> Meat Poultry and E&g Safety Bmch <br /> 1220 N StreetI Manifest'No:: <br /> Sa�aiento,CA958I4' <br /> � I <br /> :i <br /> (916 900-5O04 .. � - - • <br /> 79-124 (Est 11112) - <br /> . o-m - <br /> = a�ifst - lt+ed� iX Itchen,cease <br /> ;tec "71TxasQx , <br /> xstruc 'l ins d Relei <br /> . .. �. ' -F�.cflity Information <br /> A cOMPletelkoible Kitciie Grease�G)Ti=VOrt Manffest.for a load of JKC,cOw sts of this form <br /> :and aIIgenerator codes fironu MYFSTorm.79-125(N,Ca fest-Inedible lttehen Grease Tranport <br /> ':Generator Inform.ati6n)'foFgezier�foai-s;t contrt?inte to ate toad: Aife�rnatiFpty;the MG, . <br /> '�ri Or.ter m.ay use other forms that cont-&W all requdred Wermation. .All foram 3n each ma�fest must it <br /> .have the same Marurest Number. >ransporters�aiusfi beep.ca pYe, eIouaaifests foci==tfvo years; <br /> Manifest Instrucfiohs: <br /> .1.The driver of the IKG transport vehicle is responsible for entering all infbrmiaii0n, <br /> on this farm and on MPES Form 79- <br /> 125, Manifest-Inedible-Mchen Grease Transport,,Generator-Generator -except.for in thy.Receiving )'acility <br /> ;Representative and Generator Represen$a name am'sigrr�ure boxes. AfI entries must be in ink and legible_ The <br /> -driver must initial any corrections to information already entered: :I <br /> 15 workdays: <br /> ,2_ Enter all irtformation in the form below for each load of IKG. Give one copy of the completed form to the receiving <br /> �acilfty at'the fifhe a�•TKG e6wipt ormail or'deliverth'e copy to•the receNing-Mcirdymftin <br /> .5• Z, <br /> rL <br /> �3. Enter the Manifest Number found.at tbe.topof this form in the ManVest No. boxron the generatorform•'(MPES Form 79- � <br /> -12;5)for Each generator that coatri. ri s to the aacl: All eneratorforms from. eneiators where 1KG was =1 <br /> 9,,.. .. _g. collected i <br /> make up•tihe load must have the same Manifest Number as the attached Recerving Faci*information farm. <br /> •4. Give the generator copy(from MPES Form 7.1M25)to the generator at the time of 1KG collection or mail-'or deliver the I' <br /> copy to the generator within 45 calendar days. <br /> 5.Attach the generator forms(MPES Form 79-125)for all generators that contributed to the load.of IKG to this farm_ <br /> Maintain'this farm'arid-the aifached generator fomrs for two years from the date on this form. <br /> Date of HCG Receipt= 71rne of IKG Recaipt <br /> � Used C,aordng Oil <br /> TWO of ' r <br /> 1 � AM ,�: IKG: Intermptorlrrap Gre ze <br /> - Receiuing (FaaTrty Name: <br /> ReoaM ng Facfity �^a" " ? <br /> 275 41 WIt' 4n L _16d <br /> Total IKG Reserved: Gallons Measuring McUM Used: Corr3-ciiner Volurne`of Required): Percentage Fill(If Require : <br /> �• foundsJ� <br /> : 1 <br /> Fre -tered T otter ame: <br /> 9 rar�sp Vehicle Decal Number. .. a,i <br /> A4 <br /> Driver Mame(Prinfed): Receiving F!NTrty Rapre*ehtffwe Name(Punted}. <br /> Driver5ignafzrre: " Receiving Fadrily Represenfativ ,gnafure: <br /> ,9LOI '°N06 : 11 SIH 0l 'Gaj <br />