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5808 '�N Wb'98 : 11 SI0Z '0l 'qaj aWl j pania);N <br /> S"1;,AT�.QF CALIFQRNlA, � �� <br /> n 'ATtTWNT OF FOOD AND AGRIC'LT TURE - 7777-7- <br /> Meat, <br /> 7 7Meat,Poultry and En Safety Bich <br /> 1220 N Street . ... Manifesfi Nva:: RP, (� <br /> Sacramento,CA 95814F:1. y <br /> (910)900-5004 <br /> 79-124 (Est 11/12) ` <br /> "Manife' st - luedible' Mfchen,Grea.s'e"T $P <br /> isa o _ <br /> InstmetiOns and Receiyirm.Fara I,nformatiort <br /> fA complete InPMble Kitchen-_ reale G) irauspoz't Iklaaifest.for a load of ZKG coausists of this form <br /> _ <br /> ;aacl all generator copies frow'MPES-Toren 79-I25 (1v7C=Hest-Inedible Kitchen Grease Tr.a asport, <br /> .:Generator Infoi iatioair<)'foir$erieratois't)i f cohtr i it 1 to th'e'toatd.'Alter=flv'ely,th-e IK-G, <br /> "usporter may use other forms that contain all required information- All forms in each manifest must <br /> 'havethe same 1 Iaii� t Number."Transporters`mnsti -;cioismpl a =m ests fa>r:tcvo years.. <br /> Manifest Instructions: ?, <br /> 1-The driver of the IKG transport vehicle is responsible for entering all information on Phis fprm and on MPES 1=orrn 79- <br /> 25, Manifest-Inedible-Kitchen Grease Trans Generator-Inform,2 ion,.exr� t for in the.ReceM Facility <br /> k <br /> '�- . .pad-, . , ., .,. p � � rh! , (. <br /> �Representadve and Generator Represen#ative name and signatllre boxes. All entries must be in ink and legible_ The i <br /> driver must-initial,any corrections to information elmady.,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 ai <br /> ufacitrty'atltie time o 7KG receipt or mail or'deliverthe'copy to-the receiving-facility within-15 work.,days:• $s' <br /> 3. Enter the Manifest Number found.atthe•topbf this form in theAManrFestAo. box on the generstorfomi'(MPEs Farm 79- j <br /> °l <br /> X125)for each generator that cont-butes to tkA,,Ioad.'-All generatorforms from.generators where IKG was collected to i <br /> make up the load must have the same Manifest Number as the attached Receiving f=acility Information form. <br /> 4. Giva the generator copy(from MPES Form 79-125)to the generator atthe time of IKG collection or mail-or deliver the <br /> 'copy.to the generator within 45 calendar days. - <br /> 5.Attach the generator forret (MPES Form 79-125)for all generators that contributed to the load of 1KG to this form. <br /> Maintain this foam;'and'the attached generator forms for two years from the date on this form. <br /> Dafe of 1KC Receipt: Time of KG Receipt �--ry Used Cootdng O0 G <br /> �' Type aP !J _ <br /> y 1KG: <br /> (! PM 4 trrteraeptor/Trap Grease <br /> Receiving FaGGty Name: <br /> Rewfwing FaaT1ty'Address'." <br /> 7 , <br /> Total iKG Received. Gallons Measuring Metliba Usk: 'Conlarner VolumE�'(If Requ" ): 'Percentage Fal(If Required)- j <br /> Pounds <br /> Registered TransporterName- Vehicle Decal Numbed �1� <br /> ./ 3 <br /> f2 <br /> Driver Name(Printed): Receiving F! dy Rapresentadive Name(Printed)_ <br /> Dmrer signature: Reee in Fa'eility R enfid' Signature: <br /> - ` <br /> 8 d1�'-9C '°N - Wd88 ll—SIOZ Ol 'qa�T <br />