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i 9SS6 'ON W' :01 SIH ll d aWIi PaAIa�2�' <br /> STATE OF CALIFORI"DEPARTMENT SOF FOOD AND AGRICULTURE <br /> 4 poultry and Fgg Safety$ an <br /> rch {� <br /> I224 N Street Manifest �O:w ��3 <br /> W4 <br /> Sacramento,CA 95814 <br /> r <br /> (916)904-5004 I E <br /> 79424 (Fst.I1/12) <br /> Manifest - Inedible Yitchen Grease 'T'aransport <br /> L. <br /> fnstr�ueflons and Re+�dy*g-Facl ity Information f <br /> -A,coMplete Iuedfle KitcheA.!�req' e' fMQ)Tkansport Mao fest four a load of JKG consists of thus forms E' <br /> and all generator copies from NTESTorm 79--125 (Man-tfest-Inedible Mtchen Grease Transport ' �I <br /> Generator Nformation)for generators that 63-atribiate IKG to',the load. .Aiternstively,the IXG � <br /> transporter may rise other forms that con ;all regwired information. All formes in each maaffest must <br /> 'have the same ALMitest Nwaxber. Transportq.s.must keep completed-maWestsfor'-two Feats. i <br /> Manifest Instructions_ ! <br /> 1.Tire driver of the iKG transport vehicle is responsible for entering all information on this form and on MPES Form 79-- <br /> 125, Manifest-Inedible Kitchen Grease Transport, Glenerator Information,except for in the Receiving Facility i. <br /> Representative and Generator Representative name`�nd signature boxes. All entries must be in ink and legible. The <br /> driver must initial any corrections-to information alreiy entered; <br /> 2. I=ntel`all information in the form below for each load of IKG. Give one copy of the completed form to the receiving Y <br /> facilrfly at1he time of 1KG recCipt or mail or deliver the'copy to-the receiving facility withinJS workdays. <br /> 3. Enter the Manifest Number found at the top bf thisl'form in the Manifest No. box,on the generator form(MPES Form 79- f <br /> 425)for each generator that contributes to the Ioati. 'AIl generator forms,fram 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 lKG collection or mail or derrver the <br /> copy to the generator within 45 calendar days_ <br /> 5.Attach the generator forms(MPF-S Form 79-12§)for all generat6rs that contributed to the load of IKG to this farm- <br /> Maintain this form and the attached generatorforms;fortwo years from the date on this farm. <br /> I <br /> Dte of iKG Receipt Time of 1KG RabeiptYYFe eF L] Used Cooking Oil <br /> { <br /> IKG: Interceptortrrap Grease <br /> Rtceivmg Faoirriy Name: PV <br /> } ' 1 <br /> Receiving Facility Add�-s`"� <br /> 'natal IKG Received: Measuring Method Used: Oorib iner Volume,of Requires!)- Percentage Fill(sf r7equir�d)- <br /> Gallons <br /> L] Pounds <br /> rod-Ira Transporter Name: Vehicle Decal Number.Registe nspo J ! <br /> um ... <br /> Dover Name(Printed): ng Facility wresentative Nasse(P 1 <br /> Driver Sign e. Receiving Fa¢i1°rty epmserrtatnre g fure_' f <br /> M I1( <br /> _ II <br /> 6 'd 06H 'ON ' AVLO : ol �[H <br />