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L69L 'IN WdSl : l 0 l l ')aa ;Wli Pani ;);d ST,f1TE,QF CAQRNL4 DEPARTMINT OF FOOD AND AGRJCU.LTURF . 7 M1J Mcat,Poultry and Egg Safety Bmch �a 1220N Street Manifest NO SacraEnento,GA 95314 (916)900-5004 79-124 (I:st 11/12) 11�ani�+es - edible clien•grease :r`xi.$port. . • pr . ba-stmetiOns and Recei �a 'information f� ...,, , A complete)4kedx' ie]Kitchen'�rease G)Tra'usport Manifest,for a load of]CKG consists of this form ,,. .and all generator copies fromr'WES Yount 79-125(Manifest-Inedible kitchen Grease Transpoit, :Generator Ynfoiifiatioip)'foie geueratoirs,thaf`contitibute-IKG to the°1'oad--Alterjaatitvely,the I. G,. transporter may use.other forms that contain all required information. An forms in,each manifest must ,leave the saw Min' fest Number. Transporters must I;eep:'cam�Ieted--,manifests fof:two Fears: - Manifest Instructions: I- The driver of the IKG transport vehicle is responsible for entering ali;66 rrration on this form and on MPES Form 79- _125, Manifest-Inedible Kitchen Grease Transport;-Generator-Iriformafion,except•for in the.Receiving Facility I 'Representative and Generator Represerriaiive name and signature boxes. All entries must be in ink and Iegibie. The driver mustinival.any corrections to information already.entered; Enter all information in the form below for each load of IKG. Give one copy of the completed font to the receiving fact ,ly atlhe Ufhe of IKG rlk%iptor mail or•del'rrerthe copy to'the receiving-facilitywithin,15 work;days., ' ,. i,1 3. Enter the Manifest Number found-at th�,top'jpf this form in the Manifest NQ_ box7Lon fife generator farm (MPES Form 79- ,125)for each generator that contributes to the,,ioad_''!a!f generatorformsafrom generators where IKG was collected to :s make up the load must have the same Manifest Number as the attached Receiving Facility Information form. • t 4. Give the generator copy(from MPES Form 79-125)to the generator at the time of 1KG collection or mail or deiiver the copy-to the generator VVAhin 45 calendar days. 5.Attach the generator forms(WIPES Form 79-125)for all generators that contributed to the load of IKG to this form_ Maintain this fonn-and-the attached generator forms for two years from the date on this form. Date of IKG Receipt Time of IKG Receipt Used Cooking Oil I. Type of L J_)L_/ PM 1KG: �r- 4 ittterbeptar/Trap Grease Receiving Facility Name: CJS Receiving FaditrAddre�.," } Total IKG Received- S Y Measuring MefFiod Used: Corit�iner Volume'(if Required): Percentage Fill Of Required): x,1 jX—cellons i:I ❑ Pounds I Fiegisterad TransperterN=e: Vehicle Decd Number ; s Driver Name(Printed): Receiving Facility Pepresentaiive Name(printed): Driver Signature: Receivin Fa -ity Presentative Signature: ' d 90LO N Wd�Z l tiIOZ ll '�aQ