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STATF_Of CAuHoRRiA �ZS '°N Wdoti :E ti[O� ll '^0N auJil panicO;� DEPARTMENT OF FOOD AND AGRIMTURE --- � Meat,Poultry and Egg Safety Branch ........................._....A 1220 N Street Manifesfi No:: Sacramento,CA 95814 (916)900-5004 r` �'�r 79-124 (Est 11/m) � r L - OO t Man fest-Inedi6k Miden.G-)'r ase Tran'sart. . P t tom YnstructiOns and Receiving Faca�ity information ��.� Iete W„ , . , y _ . .. .._... .,. ,.. ,i. p Ynedible Kitchen Grease G:) Tiapsport Manifest for load of IKG consists of this form 9 and all generator copies fro aMTES Form 79-125(Maafe st W Inedible Kitchen Grease Transport, 'Generator Int' �-.•. ' orniatidiui)'fo'ir�erierators t�at'contnlinte IKG to the'Ioad.'AitexSp,a*ely,;the IKG.- y, tr TDrteir may use other forms that contai;a aU required informatirom- All forms in each,manifest must t ,have the same Manifest Nilxioaber. 3'ransportet=s`mtust Izeep:completei manifes#s#or',. o years.. Manifest Instructions: r 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 signeiure boxes. All entries must be in ink and legible. The �1 driver must initial.any corrections to information alteady,..entered, yl 2. Enter all information in the form below for each load of 1 KG_ Gere one copy of the completed farm to the receiving facility at the tune'df IKG receipt or mail or deliver the copy to the receiving faciffty within 15•work:,daysz !� 3. Enter the Manifest Number fou nd at the, ` top crf 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 ':�, make-up the load must have the same Manifest Number as the attached Receiving f=acility Information form. 1 4. Give the generator copy(from MPES Form 79-125)to the generator at the time of IKG collection or mail or deliver the ;j copy-to the generator within 45 calendar days. 5.Attach the generator€arms(MPES Form 79-125)for all generators that contributed to the load of IKG to this form_ Maintain this farm nand the attached generator forms for two years from the date on this form. i Date of!KG Receipt Time of IKG Receipt" Type of El Used Cooking Oil. PM ]KC: Intemptarrrrap Grease iaecenring Facility Name: X5- Receiving FaC4ftAddres5F— < -t, l Total 1KG Received: Ga1lOn5 Measuring Metfibd Used: 'Goritainer Volume-(I Required): Percentage Fill(if Required): j © Pounds f . G I rLi( r j - Registered Transporter Name: Vehicle beta{Number. Driver Name(Printed): Receiving Fatality Representative ame(Printed): DrHrerSgnah,re: Receiving r�Represen a Signature: 8 d Z1�0 '°N Wd3b �tiIOZ l l '^ON ':?