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r 9ti1 'IN AdI l L 'S 'APA quail paniaaad <br /> STATE OF CALTOMA <br /> )7EPA7.2'1`.LVII�NT OF FOOD AND AGFJCU.GTOPE 1l1l <br /> Meat,Poultry and Egg Safety Braoh1U12tt1 i1FeSf No <br /> _ f V <br /> 1220 N Street U`i <br /> Sa.oramemo,CA 95914 <br /> (916)900-5004 <br /> 79-124 (F9t.,11/12) <br /> _ MaY1��S�-�n.edl"iT�e�'�C�le� G`xesse Tr-•axis�or-t - � �" D2'S� a <br /> lu ruedbus and Receivb -Fac#jiy LxaLformatiom f <br /> A complete inedible Kitchen` tease jl;�Transport Manifest for a load of IICG consists of this fox-m f <br /> ._.avrd aR generator copies from MFES''Form 79-125(1Vlanifest-Inedible Kitchen Grease�'ranspo7r� j <br /> Generator InformationY for generators that co>gtil bMe ZKG td:& load= Alternatkvely,_•the EKG <br /> transporter may use other forms that conte aU required laformaiaiowa_ AIl foxing in each manffesE most { <br /> 'have the same Wfauj&stNbinber_ Transporters must keep completed-,dj�ests for-two years. <br /> Manifest Instruetions= ' <br /> 1.The driver of the lKG transport vehicle is responsible for entering ail information on this form and on MPES Form 79- ;l <br /> 'on •For in the Receiving FacIT II <br /> 925, Manifest-lnedtble Kilelten Grease Tfanspori; Generator lrlforrFra'b , except 9 ►FY 11 <br /> Representative and Generator Represen aWs name and signature boxes. /all entries must be in ink and legible. The i <br /> driver must initial any corrSCUOns.to Mformalon already entered; <br /> 2. Enter all irtformadon in the form below for each load of IKG. Give one copy of the completed form to the receiving. <br /> facjlay at jbie time of JKG receipt or mail or de&erthe copy to-ths receiving f offlitywifhin-15 workdays_ <br /> 3.Enter the Manifest Number found atthe top bf this form in the Manifest iVo,66;con the generator form(MPES Form 79- <br /> 125)for each genetn torthat coNnbutes to the.load. All geneq&rforrns•from generators where IKG was collected to <br /> make up the load must have the same Man"rl'est Number as the attached Receiving Faclrty Information form. } <br /> 4_ Give the generator copy(from MPES Form 73-125)to the generator at the time of 1KG collection or mail or deliver the L <br /> i copy to the peneratorwithin 45 calendar days_ <br /> 5.Attach the generdtorforms(MPES,Form 79-125)for all genelatDrs that contributed to the load of IKG to this form_ I <br /> :1Maintain this form and time attached genpratorfomis fortwo years from the date on this form. <br /> • _ I <br /> Date of IiGG Ren9ip Tone of IKG ReqE�ipt Type of ❑ used Cooking on <br /> �• I i`--(�' I D . PM <br /> MG. Interceptod7rap Grasse <br /> R6a6ng Famay Name: <br /> Re=ining FQaTrLyAddr�`— <br /> Talal IKG Recceiveri Maasuring IUleOioe used. Corftainervolume'pfF.3g red): Peroentago PtT(LfRequue - <br /> Gallons <br /> Pounds <br /> Registered Transporter Names Vehide Decal Number. - <br /> � 5 <br /> Driver Name(Prrnled): Recdrvn7g Mic.gRy�Pmsent3ffva Name(Ar¢rte ; d' <br /> DriveY^aignaGlrr� Ruining Fa resentative ft rte' <br /> } <br /> 6 'd 16SC 'ON WdtiZ : Z LIH 'S �pW <br />