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s��r�..t2F e�olzl� -L69L '°N WdSQ aulil paA1aa � DEPARTMENT OF FOOD AND AGRICULTURE TURF Meal,Pout y and Egg Safety Branch 1220 N Street Man;fest No.. � Sac=ento,CA 958I4 (916)900-5004 a 79-124 (Fzt 11/12) ' d lien,Gase 'Kara-.'sport 1 n)64 l Imstruettons and Reee�v!- 'Faqty Information ?,A,complete Iaedi"ble KitcheA reale G)T2psport Mazfifest.for a load of 11KG consists of this form -,"d ad generator copies fronz,MF'ES--Form 79-125 (Ma est-Inedible Kitchen Grease Transport, ' ,Generator Information)'£"air generators'tfiat-'cvAtriliinte lKG to th'e"load:'AlternativoV,the-IKG._ transporter may use other forms that contain all required information. All forms ian each manifest must shavea same e tNumber. �'f�ansporters ioalus eeli:compleite manifests f&;400 years:. Manifest Instructiohs: 1.The driver of the IKG transport vehicle is responsible for entering all information on this form and on MPES Form i9� :125, Manifest-Inedible,Krtchen Grease Transport;-Generator-information, except.for in the.Receiviriq Facility :Representative and Generator Representative name and signature boxes. All entries must be in ink and legible. The driver must.initiatany corrections to infnrmataon 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 `1 facilr7_y atthe li t7e of IKG f6wlpt,or mail or'ddliver the copy tothe rece*ing-facTrty within J15"work,.days-' ,1 ,i3. Enter the Manifest Number found at the-top,,bf this form in the ManTest No. box,pn the generator form(MPES Form 79- �1 -125)for each generator than contributes to ff!A1load.'7A11 generator forms from.generators where IKG was collected to make up the load must have the same Manifest Number as the attached Receiving F'acil'ity Information form. 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. 5_Attach the generator forms(MPES Form 79-125)for all generators that contributed to the load of IKG to this farm. Maintain this form and't ie attached generator forms for tvvo years from the date on this form. ,1 Date of IKU receipt Time of IKG Recaipt Type of ❑ Used Cooking Oil Atu1 PMIKGInterceptorlt7ap Grease aeceiv-ing FaoaTdy Name: Receiving Faa'iityAddres "="" Total 1KG Reoeived: Mea su g MetFibd used_ 'CoriWtnervorume'(If Required): Percentage 1*"il1(If t?equired): Gallons Pounds r ' Regktered Transporter Name: lVehicler Decal Numbe Driver Name(Printed): Receiving Facility Representative Name(Panted)_ Q,0 r) C,Ll Driver Signature: Re ' ing Fadi Rep n tive Signature: 7 S 'd 90L0 'ON Wd�Z t�0z l l 'aaQ . :i