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1 IH 'IN ME : [ til0 'Zl '3ny awil pan i a�;� STATE OF CAUFORNIA a DY,?ARTMENT OF FOOD AND AZ70CUL Meal,Poultry and Egg Safety Bnurch _. .. . .,. 1220 N Street Manifest No.: � R- d 1 �S Sacramento,CA 95814 (916)900-5004 79-124 (Fat l 1112) Manifest - Inedible K�t6tri Grease..T.iansport InstraCtions and Receitwing Facility Information �'" oo6 ,� VA A complete Inedible Kitcbena b cease fWQx)Transport Manifest for a load of IKG consists of this form and all generator copies from MP Storm 79-123(Manifest Inedible Kitchen Grease Transport, Generator Information)for generstors that contrxbdte IKG to the,load. Alternatively,the IKG transporter may use other forms that contain all reyu#,ed loformatiou. AD forms inn each manifest XnUSt have the same Ninnitestt Number. Transporfei;ro us'tp`comnplat4'-inifestas for two years... Manifest Instructions: 1. The driver of the IKG transport vehicle Is responsible for enterring all lnfarme n on this form and on WES Form 79- 125, Manifest-Inedible Kitchen 4rea�e Tfarmport.Generator rdionvation,except for in the Receiving Facility Representative and Generator Represei��thre nar»e'and signature boxes. All entries must be In ink and legible. The driver must initial any corrections to Icrbm> OW ahAdy.gnfsred; 2. Enter all Irdon nation in th0 form WOW for each.Ioad'of IKG, GNS one copy of the completed form to the receiving facility at the time 61 IKG r*Wpt or maN ordelhw tt*copy-tD 0)it reC8iving fad"withh-I5 work.-days. 3. Enter the Manifest Number found at the topiof thls-form in the Manifest No. boxon."generator form WIPES Form 79- . 125)for each.generator that contnbutes.to tate „load: All g"TIpr forms 9e.from, aerators where IKG was colle�-ied to make up the toad must have the same Manifest Number as the attached Receiving Fadlity Information form. 4. Give the generator copy(from MPES Form 78--125)to the generator at the time of IKG collection or mail or deliver the copy to the generator Wffltln 45 cslendar days. S. Attach the generator forms(MFES Form 79-125)for ail generators that contributed to the load of IKG to this form. Maintain this form and,the attached generator Corms for two years from the date on th'S form. Date of IKO I1C0 Type of ❑ Used CoWng Oil �— 0 � IKC3: Ir"rowwr/rrop Grease / s' Receiving Facility Nm*: ReteMN Fadli�r/kdCreaa' otal IKG Received: Measuring Mref'iod Used: Conmtrw Volume'(If Roqui ed): Percentage fit!(n Requlrgd): Gs"°rt' CY� Pounds ley Regtstermd Trortaporber Names - 1-F,Decal Plumber. I, Driver Name(Print ): Fedll4r Reproaardaeie Nmym(Primed): aS U Driver Signature: RacWng F Rep Signature: i i 9T/ET dJ_Vd N=DN oio�] 9Z6559b60z T6:ZT bTBZ/ZT/2B