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XM '°N S [H 'Ol 'q aWIi PAI Dai <br /> D"AR'IWNT SOF FOOD AND.AGRIC LTURE <br /> Meat,Poultry and Egg Safety Branch <br /> 1220 ri street Manifest No-:'W J <br /> Sac n=ento,CA 95814 <br /> (9147 90b-5004 <br /> 79-124 (Est 11112 91 <br /> _ n <br /> Manifest- ivied l+ 73ifc�ie�. ease 7['ranspor# <br /> Xxnistractions and Raced Faci��rjy Information <br /> {�1 ca fete �..�:; .•: ,,:; .;`° .L <br /> mp ed><"ble itc en Grease'�'iransport Manifest.for a,load of II�G consists of iMs forlai <br /> -.. <br /> :and all generator copies from-MPES Form 79-I.25 (1'dlax><ifest-Inedible Kitchen Grease Trauspor, , <br /> '.Generator Infnriiiation)dor ger&Ators•tbWf %fitribizte IKG to th'e°load::•Alternativety,_thr,IKG: <br /> tlrausporter may use other forms that contain,aH Iregntired information. AD forms W each mani#'est mast <br /> ;have the s <br /> ame Number.lriansporters`must keep-:co�.plete�'m'anifests folr' •two years. <br /> Manffve t Instructions: <br /> 1.The driver of the 1KG transport vehicle is responsible for entering all rnformatton on this fp7 and on MPES Form 79-- <br /> ,,12B, Manifest-inedible d<ifchen Grease Transpo t Genemtor-IriforrnaVon, except.for in the.Receiving Facility <br /> :Representative and Generator Representafive name and signature boxes_ All entries must be in ink and legible. The <br /> driver must initial.any corrections to information a.1"dy entered; _ <br /> i,2. Enter all information in the form below for each load of IKG. Give one copy of the completed form to the receiving <br /> faclTdy�t the lame of 1KG eeceiiA or mail or'deliver the copy to-the receivingfacil-rty within•-1 a-work_,days.• 1 <br /> ,13. Enter the Marfifest Number found.at the.top f this form in the Manifest Nca_ t ax,on tyle generator form(MPES Form 79- <br /> ,.125)for each generator that conWbutegs to the_rload-' AI generator forms from:genefators where!KG was collected to <br /> make up the load must have the same Manifest Number as the attached Receiving Facility Information form. <br /> L <br /> 4. Give the generator copy(from MPES Form 79-125)to the generator at the time of IKG collection or mail'or deliver the <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 1KG to this form_ <br /> Maintain this form;and-the attached genpretor forms for two years from the date on this form. <br /> Date of lKG Receipt Time of IKG Receipt Type of Used Cooking Oil <br /> r '�•' <br /> PM EKG: �•,rryrtterceptal'fTrdp Grease 'i, <br /> Receiving 1=aciGty Name: <br /> Riving>=aaTtyAddr "d•...'" <br /> • <br /> Total IKG Received: rr7nLGai(ons Measuring MethodC.lsed: Gositautar Va►ume-((f Required}: 'Percentage Fi11(!f Required}: <br /> Pounds •��� <br /> ❑ C� <br /> Registered TransporterName, Vehicle Decal Number- <br /> 7 <br /> umbera;i <br /> S <br /> l/1� <br /> C <br /> Driver Name(Print4: Receiving Facility Represen afive Name(Printed): <br /> 1 <br /> Driver Signature= '' Rwe iving Fadrdy Rep nt2tive Signature: <br /> Z d'-"'9CN WHLO ll`SIOZ Ol 'pj ;: <br />