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LHL "N Wdti0 :9 9l0Z S u��^coil pania3a� STAT2 OF CALIFORNIA (i DEPARTMENT OF FO AND A�GR�CIJX.TUl� � ;� mea%Poultry and Egg Safety$ranch Manifest No::�L�4 1220 N Street Sacramento,CA. 95914 (916)900-5004 79-124 (FzL I1/12) Manifest Ice i nble jGtchen Grease Transport I ' ' for>nnatlon L Ilnstrucdon.s and Reeei. g Fac�ty ort Manffest for a load of JKG consists of this form t 'A complete Inech'ble KitcheT�Grease C 'f`zans - 2nd all g enerator copies from.AVES'^Folrm 79-125 (Manifest-Yuedilble Tsiteheaa Grease� I�G�� Generator Tnfarmatioxtj'for ge>derators that c6ntlribute)KG tti the load. Alternates elp, tramporter may use other foarms that contain all required b3format#on. All forms in each manifest must p Transporters must keep completed,iiaan fests for.two years. 'have the same maWest Number. Il Manifest Instructions: � risible for entering all.information on this form and on MFES Form 79- 1.The driver of the 1KG transport vehicle is respo }I 7 , Manifest-1nt:dible Kitchen Grease Traneport, �aener,Aor Inforrnaton,-except for-in the Receiving Facility Representative and Generator Representative name and signature boxes. All entries must be In Infc and legible. The P } driver must initial any corrections,to information already entered; receiving the re 2. Enter all information in the form below for each load of IKG- Give one copy of the completed form to facility at the time of!KG receipfi or mail or deliver the copy to,the receiving f3cifTtywithin-45 work.days- 3. Enter the Manifest Number found at the top fJf this form in MarII No- b form front �erators where#KG was.6n the generator (collected to ES Form 79 125)for each generator that contributes tO tl`1 load. All generatr,r . ,. . 9 mace up the load must have the same Manifest Number as the attached Receiving Facility information form. 4_Give the generator copy(from MPES FoT m 79-125)to the generator at the time of EKG collection or mail or deliver the copy to the generatorwithin 45 calendar days. _ 5.Attach the generator forms(MPES f=orm 79-125)for all generators that cotriad s the Ick of#KG to this form. Maintain this form and the attached generator forms for two years from the date on 172: Type Li used Cooking Oil 1 ERLi,�ilvrmg Receipt rime of iKC ReceiptPTNIKG: _ /InterceptorlTrap GreaseaaTrty Name: Receiving Faul-dy,43dress � �� " POrG�nte 6 mil If R t1irE Measuring od Used: Corstainer Volume'(If Re4ui ): 9 Total IiCC Received: �/ �llens /f �D PoundsCJ tclV Vehicle Decal Number •-- - Registered Transporter Name: + , - Deceiving FacTrt�f R2prasentat'svE x131]76(Printed: 1 Driver Name(Printed)- f 'ice `r y n Fadfi�r Rep ntative Signature;' 'Ura- 'd li �� 'd SZ60 '�N Md : 9 ISM 'S