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1189 "N Ad8Z : l til0l Zl 'end quail paniaaa� STA' Of CALIFORNIA w .� DEPART1 MNT 'OF FO OA AND AGRICULTURE Meat,Poultry and Egg Safety Branch _ Manifest No.: R e c�c ]?20 N Street Sacramento,CA 95814 (916)900-50041 . 79-124 (Est 11/12) J. Manifest r Inedible Kitchen Grease Transport Instru "• ,,,,, „and ReceiviBg Facility Information A complete Inedible Kitch = G)Transport Manifest for a load of IKG consists of this form and all generator copies fiv4-AtftSTorm 79-1.25 (Manifest-Inedible kitchen Grease Transport, Generator Information) for g"e—erators that contribute IKG to the load_ Alternatively,the IKG , 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. 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 Representative and Generator Representative name and signature boxes. All entries must be in ink and legible. The driver must initial any corrections to information already entered. i ! of th®,co feted form to the receiving .i 2. Enter all information In the form below for eact�•Aoad of IKG. Give one copy P facility at the time of IKG receipt or mail or deliver'the copy to the receiving facility within 15 work days. . 31 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 i make up the load must have"same Manifest Number as the attached Receiving Facility Information form. 4. Give the g PY generator co (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. generator forms MPES Form 79-125)for all generators that contributed to the load of IKG to this form. `I 5.Attach the ( i Maintain this form and the attached generator forms for two years from the date on this form. xl Time of IKG Receipt: Used Cooking Oil Date of-IKG ecelpt Type of � IKG: // PM ifq/lnten,.eptorlfrap Grease Receiving Facility Nome. LJ R(!�wing Fac111ty Address:' 127 / 2 y� alai IKG Received: Measuring(Method Used: Container�Ium, If Required)= Percentage F111(if Required); .� �Gsllons �� z— . Pounds /�� "l / Ftegiste Transporter Name: l ( Vehicle Decal Number S ass Driver Name(Printed); RaceNing Faciltty Representative Name(Printed)' A Driver Signature: Romiving Facility Representative Signature: .s �R 91/b0 3E)Hd a3ioo�1 oio'j 9Z6559b60Z Tc :ZT VTOZ/ZT/80