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f <br /> j_ 60H '°N Md : [ EH '9 [ "Ir IwIl PIAI ;D;d <br /> DaAS PF FOOD AND AGRIC'UX, <br /> Meat,Poulay � Egg Safety Brach - - <br /> 1,2.0.N Street JAN 1 20i� Manifest'N1o:: <br /> Sacramento,CA5814 <br /> (916)900-5004'i ENVIRDNMEWk HEALTH j <br /> 79-124 flERMtT/SE <br /> ( .rl1l2) RVICES I �) <br /> 'i manifest"=. ed >iileEchen,Grease ' 'ran:spor->t - <br /> Instructi <br /> bns xnd Reeeivag F'aci�ity-�or�m.ation it <br /> ....tiSi,, .,y... <br /> A completeI edli`�le Kitchen�igease 03 ��Tira�asport IVlaldifest.for aload of 10KG consists of this form <br /> -and allgen ii or copies froniN PES-F'orm.79_125 (Manifest-Inedible Mtchen Grease Tr"o3rt, <br /> }' <br /> -Generator haiation)-foil gexwrooft tliAi,-pd '1KG 6 th-d°lo'k&-Aiternatraety;the"IKG, <br /> -transporter y use other folrpas that con"allreqfted iiAfoxmatiton_. AA forms in each marafest wixst <br /> ftVe tote sarni 'l an�fest Nzimber. :Transporte-im iRut�st beep eomplete��anifests fox.tw•o years: <br /> . y - I <br /> !Manifest In otions. ' <br /> 1. The driver o;l a IKG�Lransport ve1iide Is responsible'for entenng all information on this form and on NrPES Forrn 79- <br /> :125, Manifest ;I edible K>tchen Grease Trarisp�ort;:q*nera6r,Inforrxtation,-except-for in thei,ReoWmg Facility ` <br /> Representative',i d Generator Repres®ntatavep;ame and'sign ul b xes_ All entries must be in ink and legible. The 'l <br /> 'driver must inti .any corrections to InTOffie'tion a mady.entpred I <br /> ;2. Enter all ictfo ation in the fiorm b fdw for each load of IKG.: Give-'one copy of the completed form to thelTeceiving, <br /> fadiffly et h tt of lKG r eo�jpt or mail or deliver the.'copy to the.r•eceiving- Facility within-°I 5-work_days_ <br /> ti <br /> f s, <br /> 3_ Enter the M (fest Number foupd at the top,of tats form�1 --the Manifest No. box.on the generator form(MPES Form 79- <br /> 12a.)for each 9, ` erator that contributes to fJie,load:'All generatorforms from generators where IKG was collected to a j <br /> make up the I must have the same Manifest'Ndmber as the attached Receiving Facility Information form. <br /> 4. Give the gen r`ator copy(from MPES Form 79-125)to the generator atthe time of IKG collection or maWor deliver the <br /> copy <br /> to the gen' torwithin 45 calendar days. <br /> 5.Attach the g �r4or forms MPES Form 79-125 for all generators that contributed to the load of I KG to this form. �I <br /> Maintain this fo 'and'the attached generatorfomis for two years from the date on this form. <br /> Date of IKG Remip Time of IKG Race!p� Used ooking Oil <br /> C <br /> TYPO of ❑ I <br /> AP IKG: Irtterceptorrap Grease <br /> I �' a <br /> Rer�iving FaaTr�y N e: <br /> Receiving Facility <br /> 7vtallKGReceived i � Gallons MeasuringMe(fiodCased Cortt-ainerVolume'"(IfRa iced): Percentage Fill!(IfRequired):El <j.I <br /> Pounds <br /> Registered Tia P12m0. Vehicle Decal Number. i ?' <br /> mc <br /> Driver Nalin 'N <br /> (t' Receiving Faaltty P„epreserrtaiiva Name(printed): <br /> �I II II .. .... i. <br /> Driver Signature: Rec6rJng Facility Representative Signature: <br /> L,,,,JF I <br /> i <br /> Z 'd "j 6656 'IN WdLS : l EH '9l 'u�r <br />