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X808 '°N Wd�B ll 510 0 [ ,q;j moil pania°;� <br /> sTk,TF,r3F CAW 0RMk <br /> DEP;�-RTIVIENT SOF FOpXI AND AG,$ICULTrUFF <br /> Mem poultry and E ;Sai ety Branch <br /> 1220N strut Manifest No;: 12-Q { ) !E; <br /> Sacraneinto,CA 95814 <br /> (976)900.5404 : .° 7 ^; <br /> 79-I24 (Est 11/12) k—, 1 c��I <br /> Nlnifest.— 7tted�l�i tcen + "r7['ea 'e �'Y: , E <br /> S ?ri'spo7r-t <br /> Instruc�ibns and Ree F`aeility Inforlmat%on ' <br /> f E� (3m lEet@�IL�dl )le <br /> p schen Gz'eas� ,G)'Ti apsp <br /> Cort Manifest.for a load of MG consistsof this foam <br /> and aU generator copies D-oni'MPES',Form 79425(Manifest-.1nedible Kitchen Grease tr.2 4sptrrt, <br /> ',Gelierator Trifoiriatieni)foir gezie7rato�t s tfi r>-coritn'iiute JKG to th'e'lo'a :'Ai€erna"iy,.the JXG,. <br /> transporter msy use other form that contain all required informatitoaa.. All forms in each mangiest must <br /> ?have the same ITnmber. �'xsporteTs"ri>tust keep:capietedmniofests far'=two pears; <br /> Manifest lnstructiohs: <br /> 1.The driver of the IKG transport vehicle is responsible for entering ali`information on this form and'on MPES f=orm 79- <br /> :125, Manifest�Inedible Xitchen Grease Transpart,_Generator-Information,except-for in the Receiving Facility � <br /> .;RePresentative and Generator Ftepreseniaf ve name and3 sig':a- ure boxes. All entries must be in ink and legible. The i. <br /> ,:driver must Initial.any corrections to information already-entered,:' <br /> r;2. Enter all information in the form below for each load of IKG. Give one copy of the completed form to the receiving <br /> fabUi,ty at'the bine oT TKG receipt or mail or'deiiver izi•i'e copy to the receiving-facilityw- <br /> ithin1 5 workd�ays: <br /> 3. Enter the Manifest.Numberfoundi.at the.to��of this form in the IVlan�fest lVo. �iox on the generator form(MPES Form 79- y` <br /> °US)for each generator that contributes ft'the,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 1KG collection or mall'or deliver the <br /> copy.to the gpnes4tor within 45 calendar days- _ <br /> 5.A=r-h the generator forms(MPES Form 79-125)for all generators that contributed to the load of 1KG to this form. <br /> Maintain this form;and-the attached generator forms for two years from the date on this,form. <br /> DZ of 1KG Receipt Time of 1KG Receipt <br /> '�ypS Of 0 �Used Cookie Oil <br /> 'f <br /> / <br /> AM PM iKG:� Irhemeptorl'1"rap Grease <br /> Re6g ing Facirrty Marne 1 <br /> Receiving FaotTrtyAddre,§2F ' '" <br /> Total 1KG Received_ Meastirmg Medi6d Used: 'Container volume(if R ui � <br /> Gallons �l �� '-Percentage Filt pf Required): <br /> I <br /> ❑- Pounds <br /> Registered TransporterName Co Vehicle Decal Number. <br /> AL QAn— Poofe_r _Tll�� 3 , , <br /> F <br /> Driver Name(Printed): Receiving FaG7rtti+Reprc n a Name(Printed): <br /> Driver Signature- Receavi F cirrty Re resents Signature: <br /> er .j <br /> 01 'd-9« � '°N <br />