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96L6 "N WdtiS :Z S 'til '100 aW11 P;ni ;)ad STATE OF CALiFOPMA 1� DEPARTMENT OF FOOD AND A.GRTCUL'IV Ih Meat,Poultry and Egg Safety Branch 3220 N Street Manifest No:: ��✓ Sacrau to,CA 95814 (916)900-5004 r 79-124 (Est 11/12) manifest - IneWble Kitchen Grease Transport Instructions and ReceivilntgTaOil Wolrmation � 'A,complete Inedible Kitchen g ;� rease Q)T ramport Manifest for a load of 11KG consists of:this form ..and all generator copies from MPES',Form 79-125 (1 LmUest-Inedible Kitchen Grease TSrsiaspor , Generator Triforniation)-for generators that c6ritrj0bute)0KG td he-ioad. ,AlternativeIn.the W _ txansrporter ioraay use other fora s that contain all required information. All forms in each manifest must { 'have the same Maniiest Number. TSramsporters must keep compkted-majdlfests for two years. Manifest Instructions: 1.The driver of the IKG transport vehicle is responsible for entering all information on this form and on MPES Form 79- it :125, Manifest-Inedible KAchen Grease Transport, Generabor Informatio'n,'-except for In the Reoeiving Facility Representative and Generator Representative name and signature boxes. All entries must be in ink and legible. The !l driver must initial any corrections.to ilnformaton 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 faoili y at the time of 1KG recOlpt or niail or deliver the copy to-the receiving faciffiy within 15 work-days. � 3. Enter the Manifest Number found at the top bf this form in the Manifest No. box,on the generator form(MPES Form 79- .125)for each generator that contributes to the.load_ All gipneratorforms 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.. arm_4. Give the generator copy(from MFrES Form 79-125)to the generator at the time of IKG collection or mail or deliver the copy to the generator within 45 calendar days. 5.Attach the generator forms (MPES Form 79-125)for all generators that contributed to the load of IKG to this form. II Maintain this form and the attached generator forms for two years from the date on this form. Data of KG Receipt ✓ Time of IKG Receipt Used-Cooking Oil T 'G PM IKG:0 ,,.4ntermptor/Trap Grease l Ld' Recanting Facility Name_ Receiving FaaTity Addresd----`' Total lKG Received: Measuring Method Used: ContmnerVolume'(lf Required): Percentaga FII(If Required): El—Gallans Pounds Registered Transporter Name` Vehicle Decal NumbeC. Driver Name(Printad): Receiving Fatality Representative Nams(Print: river Signature- ReciMng Fadlity Representative Signature:4L, i t L 'd �6ti 'ON Wd9S : Z SIE