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ii 9SS6 'ON N00 :0I SM 'd IS aldI J panI I I STAT&OF CA1IF0?dZA 1�► T Imo''OF FOOD AND AGRICULTURE rr Meat,Poultry and Egg Safety 13 mol; llli�nifest No:: 1220 N Street , �,J Saommento,CA 95914 . f (91 6)900-5004 i 79-124 (Est.11112) i Manifest •- Xne dible 10tchen Grease Transport Instrluefions and Ree 'A g•FaeiHi Information A complete Inedible Kxtehela Greae' `G)Transport Manifest for a load of IKG consists of.this form I and all.generator copies from MPES-Form 79-125 (Manifest-Inedible Kitchen Grease Transport, Generator Information) for generators that contribute IKG to'the•load. Alterna"ig,the II�G , transporter may use.other fors that containa'all required information. All forms in each waWest must } 'have the same Manifest Number. Transpoirtexs must beep completed-mauifests_�foz.twvo years. k Manifest Instructions: � jl 1.The driver of the IKG transport vehicle is responsiyie for entering all in on this form and on MPES Form 7� :125, Manifest-Inedible ICrtchen Grease Transport, Generator Information,•except for in the Receiving Facility �- Representative and Generator Representative name and signature boxes. All entries must be in ink and legible. The it driver must initial any corrections.to information already entered; I. 2. Enter all information in the form below for each load of IK(3. Give one copy of the completed fonn to the receiving f facilfty at the time of IKG recbipt or marl or deliver the copy to-the rec*iving facility within-15 work-days. �I �t 3. Enter the Manifest Number found at the:top bf this1form in the Manifest No_ box,on the generator form(MPES Fort 79- 125)for each generator that wntributes to the load. All generator.forms from generators where IKG was collected to make up the load must have the same Manftst Number as the.attached Deceiving Facility Information form_ 4. Give the generator copy(from MPES Form 79-125)to the generator at the time of IKG collection cr mail or deliver the copy to the generator within 45 calendar days. +# 5_Attach the genes-atorforms(MPES Form 79-125)for all genera 6rs that,contributed to the load of CKG to this form_ j Maintain this form and the attached denerator forms'for two years from the date on this form. 14 2 pate of 1KG Receipt Tune of lKG RebeiptTypeUsed Cooking Oil gPM IKG: G Intermptorrrmp Grease ;I FWoeMng FaaTrty Name: l j� S, _ f Rec-rviwlnq.FacilityAddress'_' 12 S 61 > 1-1 G rV � Total IKG Received: Measuring Method Used: r�arradiner Vo ume(]f equirnd): Penuentage Fill(If Required): ��.Gallons Pounds C � G Registered Transporter Name: Vehicle Decal Number: ' 12SS C - i�ver- 7� 7 . Driver Narne(Printed): Rao&Mng Facility Representative Name(Prir)t�c l); Driver Signature: Re17ng Facility Representative Signature: L 'd 06z� 'ON WHLO Ol SM l l 'daS