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1199 '°N NE : 1 til0l Zl '°nN a' i l pan <br /> STATE OF CAUfORNiA Cisco= <br /> DEPARTMENT UP D AND AG CUL <br /> Meat;Poultry-and Egg Safety gTmC11 =.. .. . . - ,.....,..,. Manifest No.' <br /> 1220 N Street <br /> Sacramento,CA 95814 <br /> -5004 <br /> (916)900, <br /> 79-124 (Est 11112) <br /> Maaif�st - ne bre Kitchen Grease Transport <br /> I>nstxuc�ions and Rece' g'Fac*,q Igforllmation x <br /> A complete Inedible Kitchenrrease�)�`rAn po <br /> Manifest for a load of IKG eolasists of this forms <br /> Inedible Kitchell Grease Transport, <br /> and aH generator copies from MPF.S'Form 79-125 0211iifest. <br /> :Generator information)for generators ` <br /> that co111t3tMiite'MG`.tio'the,loitd. Alternatively,the IKG <br /> `trnl,,porter may use other forms that.cont2iR stll required informat,�on. All.>>'orms in each man>tfest t'ist <br /> 'have the same Manifest Number. Transporteis must ki�ep«�npleted+m este folr two year$. <br /> Manifest Instructions: <br /> 1. Th0 driver of the IKG transport vehicle is respo,nsib <br /> le for erlbering all informationon this form and on MPES Form 79- <br /> L3enerabC r intorma m,eXCW fo in,ft <br /> Receiving Facility <br /> 125, Manifest-Inedible Kfthon Gre a"T :. <br /> Representative and Generator Representative name and_slonabure boxes; Aft entries must be in ink and legible. The <br /> :duvet niust initial any correcttons to infornnatan.altdY <br /> 2 .EnQar all it rtnation in tkle form below for eat load of IKG. Give one copy of the completed.form to the receiving <br /> facinty at ft time of IKG receipt or mall or"deliver the�t�`tht re0blvin9 <br /> u►ithirM 5 workdays-- <br /> Number found at the top�1f th form enerzltor form(MPES Form 79- r ' <br /> In the Manifest No. box,on the g `. <br /> 3. <br /> Enter the Manifest N ���'���Where IKG ares collected to <br /> 125)for each generahorthat contributes to the..lee4. All,9W%f-z# Fadi Information fnrrn, y' <br /> make up the load must have the same Manifest Number as the attached Receiving nY <br /> 4.Give the generator copy(from MPES Form 79-125)to the generator at the time of iKG collection or mail or deliver the <br /> Conto the generator within 45 calender deYs. - <br /> 5. Attach the generator torms(MPFES Farm 79-125)for all generators that contributed to the k)ad of IKG to this form. <br /> Maintain ails form and if%e atZerctied generator forms for two yeaTYW rs from the date on this gam. <br /> t a ❑ Used Coo"Oil <br /> L� F" 1 lrrap Grease f <br /> N0rv1e: r <br /> � � �,Q�I ----������L; .u�. i <br /> f2 7 CdtRa?16r VOEUrt10(1t Requ6c)) rereftfaQe Flit(1f Required): <br /> otal IKG Rlreehbd: <br /> �(` ger , •+ <br /> Reg�TrArSPOWNasUA: —7k— ^6D <br /> ��i�CZSg h oda O l�Fv�"0Nam( i <br /> Driver Nae*(Porgy): d <br /> 45 <br /> 9T11/TT DD-Vd �J3100�1 Oio�j TE :ZT btezizt/ae <br />