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"' ��SL 'oN WdQ� til0 'A ON awil pani STATE OF CALIFORNIA PEP'ARTMENT SOF FOOD AN AGRICULTURE Meal;,Pdultry and Egg Safety Bzanclt anlf@S'� NO:" i) 1220 N Street ,�.-: ,. . . -,1/ ,f=T` ^(✓ Sacramento,CA 95814 ;. (916)900-5004 i 79-124 (Fsc 11112) Manifest'- Inedible Kitchen Grease Tiransport Instructions and Receiving Facility Informlation 'A complete Inedible Kitchen Presse PXG)Transport Manifest for a load of TKG consists of this form � I and all generator copies from NTES'Form 79-125 (Manifest-Inedible Vitchen Grease Transport, Generator Information)for generators that contribute IKG to the load. Alternatively,the WG � tramporte>r may use other forms that contaiiu all required information. All forms in each manifest locust � !! 'have the same Manifest Number. Transpoirteri must keep complked-iruari-ifests for two years. Manifest Instructions: 1-The driver of the IKG transport vehicle is responsible for entering all information on this faorm 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- 2, Enter"all information in the farm below for each load of IKG. Give one copy of the completed form to the receiving facity at the time of IKG receipt or mail or deliver the copy to the receiving facility within-15 workdays. p`< f 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 cvntlributes to the.load. A!I generator forms front generators where lKG was collected to make up the load must have the same Manifest Number as the attached Receiving Facility 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_ 0 5.Attach the generator forms(MPES Form 79-125)for all generators that contributed to the load of IKG to this form- MaIMM this form and the attached generator forms for two years from the date on this form. Date of IKG Ti Re-ceipr me of 1KG Receipt T of ❑ Used C king Oil ^, } Yl I C 2 I AM PM IKG- 1nCercepiorlTrap Grease ; I t l: Receiving Facility Name: Receiving Facility Address ""„`” r{ Total 1KG Received: Gallons Measuring Method Used: Contalner Volume(if Required): Percentage Fill(If Required): ❑ Pounds , r -- �} 75 I Registered Tmnsporter-Name: Vehicle Decal Number: �- Driver Name(Printed): Receiving Facility Ronesentative Name(Printed): Al Driver Sig Receiving Facility Representative Signature' .� �`ZIcQ '�N WdLti � � tiIQZ 'l l noN .r