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9616 "N WdtiS :l SI0 a0 ;UJ il p;Aizza� SLA CS OF CALWORNiA -� DEPARTMENT QF FOOD AND AGRICULTURE Meat Poultry and Egg Safety Stanch i 1220 rl street Manifest No:: �1 Sacramento,CA 95S 14 (916)90G-5004 i 79-124 (EsL 11/12) r Manifesit - Iiaedibie Kitcheln Girease T"ra'spor-t InstructilUns and Receiviug-Facility Information �a 'A complete Inedible Kitchen Grease 01[�GTransport Manifest for a load of IKG consists of this form :.and all generator copies from I PES^Form 79-125 (Manifest-•Inedible Kitchen Grease Trawpor4 Generator Information,)'for generators drat cdiit i bite ICBG to:the•load. Alternat"br,tb.e IKG transporter may use.other forms that contain all required information. All forms in each manifest must i 'have the same Manifest Nr6 beer Traxtspoiters'must keep compUted•j-mazanfesfs-for.two years. I Manifest Instructions: ;I 1. The driver of the IKG transport vehicle is responsible for entering all information on this form and on MPES Form 79- ;l 125, Manifest-Inedible Kitchen Grease Transport, Generator Inforr afion,.except for in the Receiving Facility 'I Representative and Generator RepresentatSve name and signature boxes. All entries must be in Ink and legible. The driver must initial any corrections.to information already entered; 2. Enter all information in the form below for each load of IKG. Give one copy of the completed form to the receiving f2cildy at the time of 1KG receipt or riiah or definer the copy to the receiving facility within 15 work.days. I 3. Enter the Manifest Number found at the top pf this form in the Manifest No. box•on the generator form(MPES Form 79- 125)for each generator that contributes to the load. Al generptor forms from generators where IKG was collected to make up the load must have the same Manifest Number as the attached Receiving Facility Information form_ 4. Give the generator copy(from MPES Form 79•-125)to the generator at the time of 1KG collection or mail or deliver the copy to the generator within 45 calendar days_ 5.AMoh the generator forms(MPE:i Form 79-125)for all generators that contributed to the load of IKG to this form. �I Maintain this form and the attached jenerator forms for two years from the date on this form. Dat:!of}KG Receipt Time of IKG R ipt Used Coaldng Oil Type of PM IKG: lrrterceptorfrap Grease ' Receiving Faci ity Name: Receiving Facility Address / XY V pn- Czl Lc)dr e6 Total lKG Received. (Gallons Measuring Method Used: Container Volume'pf Required): Percentage Fill(lf Required): Pounds Registered Transporter.Name: Vehicle Decal Number. ' Driver Name(Printed): Receiving Fact ity Reprnsentaf3ve Name(Printed): j2005(-,.JdA 11tol) . r OriverSignature: Receiv OT-V Representative Signature:' 6 'd H6 'ON Wd9S Z SIOZ til '��oi�