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} 1129 N ME : [ ti[Ol 'Z1 '2nd ;wi j paAia�na� STATE OF CA1.1F.ORNIA DEPARTMENT OF FOOD AND AGRICULTURE Meat,Poultry and Egg Safety Branch Manifest No.: R _ � "- 1220 N Street Sacramento,CA 95814 (916)900-5004 I 79-120. (EL st 11/12) Manifest - Inedible Kitchen Grease Transport fnstrxkslft�"s and Receiving Facifity Information A complete Inedible Kitchtp e fIXG)Transport Manifest for a load of IKG consists of this form and all generator copies from '`�'orm 79-125 (Manifest-Inedible Kitchen Grease Transport, Generator Informatiion)for genehators that contribute IKG to the load. Alternatively,the 1KG transporter may use other forms that contain all required information. All forms in each manifest must have the same Manifest Number. Transporters must keep completed manifests for two years. j Manifest Instructions: 1.The driver of the IKG transport vehicle is responsible for entering all information on this form and on MPES Form 79- 125, Manifest-Inedible Kitchen Grease Transport, Generator Information, except for in the Receiving Facility me and signature boxes. All entries must be in ink and legible. The Representative and Generator Representative na driver must initial any corrections to information already entered. 2. Enter all information in the form below for each load of IKG. Give one copy of the completed form to the receiving facility at the time of IKG receipt or mall or deliverthe copy to the receiving facility within 15 work days. l 3. Enter the Manifest Number found at the top of this form in the Manifest No. box.on the generator form (MPES Form 79- , 125)for each generator that contributes to the load. All generator forms from generators where IKG-was collected to Number as the attached Receiving Facility Information form_ make up the load must have the same Manifest 4. Give the generator copy(from MPES Form 79-125)to the generator at the time of IKG collection or mail or deliver the copy to the generator within 45 calendar days. 25)for all generators that contributed to the load of IKG to this form. 5. Attach the generator forms (MPES Form 79-'1 Maintain this form and the attached generator forms for two years from the date on this form. Date of IKG Receipt: l imp,of IKG Receipt: T of used Cooking oil Type 11 ,70 Am IKG: Interceptor/Trap Grease. Receiving Facility Name; Receiving Facility Address: Total IKG Received: Measuring Method Used: Container Volume(If Required): Perceni2ge Fill(if Required): ��allons ''7 �y0 s� I—I Pounds /� /r r 6kJ Registered Transporter Name; ( vehicle Decal Number. Sz Driver Name(Printed): Receiving cility Representative Name(Printed): Driver Signature: Rece- ing Facility Re resen ive ignature: a 9T/90 39-vd i'1d10MJ 0104 9Z6559b60Z TE:ZT bTOZ/ZT/80