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STATE of CALIFORNIA 1129 "N W d S l ' l ti l O Z Z G ''n y a w 1 p a n 1 a a'a� ; <br /> -DEPARMNT OF YMB AND AGRIMIM <br /> Meat,Poultry and Egg Safety Branch <br /> Manifest No:: <br /> a <br /> 1220 N Street � <br /> Sacramento GA 95814 r <br /> (916)900-5004 PY <br /> 79-124 (ESL 11/12) <br /> Manifest - Inedible.Kitchen G Tease TrA p . <br /> Instructions and Receiving Facitlilty Information <br /> A complete Inedible Kitahel>lt-Oxegae MOGQl franspo Manifest for a load of IKG consists of this form L. <br /> . rt <br /> �1 <br /> and all..generator.copies>�o N .4�Foirfm 79-�?S(Manifest-Inedible Kitchen Grease Transport, <br /> Generator Inforfita�ation)for gen—t-1ors*at cN ti bd� IKG to-the loa& Alternativety,_ihe IKG. , <br /> transporter may use other forms that,contain 80 required inforfttaatton. All forms in each manifest must <br /> „ <br /> have the same est er. fir,.iimns.. porters must compleberlt kaki#egtfs oir two years.- <br /> Numb , <br /> Manly Ifnstruc"O", <br /> tnrtq <br /> 1.Thedriver of the IKG transport vehlde is rf3spor$ibie.;for ertteallinfdrtnation on.this form and on MPES Form 79- <br /> 125, ManNest-Inedible ctw Grease Tfansport, GenenAx IrrtY�rt for in the Raoeh►ing Facility <br /> Kr <br /> Representative and Generator ftepreser`t ative'h :j34st9ii 6boxes. All entrees must be In Ink and legible. 'The <br /> driver must initial any corrections to informadon.atready erl>areld <br /> '. 2. Enter all information in the form below for eoch.,1ped of IKG. Give one copy of the completed form to the receiving <br /> facility at the time of IKG riecelpt or mail-or ddlf mrttte to the recaftV fatcilitywithirr-15 workAWs. +, <br /> 3. Enter the Manifest <br /> -, . .k. <br /> Number found,at the:�ap bf this form in they Manifest No. box;on.the generator tbrrrr(MPES Form 79- <br /> 125)for each.generator that rpntri6uters_to'9�e„ioad.�•All generabor'.forms,from,ger�'rs WtWre�IKG was collected to <br /> ! . <br /> make up the bad must have the sameManifest Number as the attached Receiving Facility Information form. <br /> 4. Give the generator copy(from MPES Form 79-126)to the generator at the time of IKG collection or mail or deliv6f the <br /> copy to the genera within 45 calendar days. _ <br /> 5.Attach the generator forms(MPES Form 79-125)for all generators that contributed to the bad of IKG to this form. <br /> maintaln this.fcrm and the attached generator forms for two years from the date on thls.form. <br /> Deft Type of Used Cool fag Oil <br /> n r PM 1K0: Interceptorfrrap Grease <br /> Re=Mnq FaCft Nam: <br /> ,L <br /> RaoeMng Facility AdtdresC <br /> LAX <br /> (�. COrtt8D*r Vok=e�tf Required): Perdm�FID(If Required): <br /> otal IKc lZeCetved: � � C} <br /> Pounds Lalli'hll <br /> Registered TraR orW Names Dowl Number <br /> 5 ►�P.�s (� dn- 2nd <br /> 7”; X90 3 <br /> Dtiver.Nsme(Pthftd): ReceMN Fscil ly RapnwerO ft Norm(Ptfited): <br /> d e L)C., rr`� N `�v►t} <br /> DrNet Signature: ReqMv Facile,Rqjasentow Iftrature, <br /> 9T/5T 39Vd H=0�1 OiOd 9Z6559760Z T6 :ZT 7TOZ/ZT/20 <br />