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99ti1 'IN WdSl :l LI0 S 'ApA awil paAI ;3;d <br /> SLA-MOF CAL70RWA <br /> AEPARTDI NT'OF FOOD AND A.GWCUL1L`U_RE <br /> Mead,Poultry and Egg Safety Braach � <br /> Izzo N saw Manifest No:: R Rr(� 17 <br /> Sacr=emo,CA 95814 <br /> (916)90o`s004 <br /> i <br /> 79-124 0Fsz.1V12) <br /> Manffest Yned0le schen GX-ease Transport - /��J�•--� <br /> Instructions and Reee' ' Facility Wbrmatti,on lJ (��j 1 � <br /> A complete InedaWe Mtchen ease fffKQ Transport P4anilfest for a load of UKG consists of this Form <br /> ,and aU generator copies from AIMS°Form'79-125(Alauffest-InedilbXe 10tcben Grease Transport, ' <br /> Generator Wormationy for generators'triad WAtfi bate TKG td*the load. A]W matzo ,the l&G . � <br /> transporter xua-y use other forms tbat contatm an regtired hifoxmation. .AIl norms in each mau4fest must <br /> -brave the same 1V�Number- 7ransporbers tansy he-ep compWed-ffhaxizfes&for-two pears. <br /> Manifest Instructions: l <br /> 1-The driver of the IKG transport vehicle is responsible for entering all in-fbrmadon on this form and on MPES Form 79- it <br /> 125,Manifest-Inedible Kitchen Grease TfansportF Genera&ur Informaiitin,'-exceptfor in the Deceiving FaciTity ¢t <br /> Representative and Generator Representafive name and sighature boxes. All entries must be in ink and legible, The (� <br /> driver must infftl any coirectiorwsto inforrrrafion already entered; <br /> 2- Enter all irlformafion in the form below for each load of IKG- Give one oppy of the completed form to the receiving, <br /> fac!W atthe time of IKG receipt or mail or deTiverthe copy to'the reclrving facifrtywithirt-FS:work.days: I <br /> ,S_Enter the Manifest Number found at the top pfthis form in the Man-di;a No. 17oz.On the generator form(MPES Form 79- <br /> -12v5)for each generatorthat contrtbutes to the-load- All generaxorfamna from generators where IKG was collected to <br /> make up the load must have the same Manifest Number as the attached Receiving Facifty In%miaffan fom-L f <br /> 4_ Give the generator copy(from Mpr-S Form 79-125)to the generator at the time of lKG collection or mail or deliver the <br /> I copy to the pneratorwithln 45 calendar days. <br /> 5_Attach the genergtorfbrms(MPES Form 79-125)for all generators that contributed to the load of IKG to this-Form_ I <br /> -Maintain this form and Me attached genpraforfvrms for two years from the date on irhis form_ j <br /> Date of IKG Rwept Time of IKS Reaagpt ---1 U5ad CooMng Od <br /> �{ Type of IJ i <br /> 1KG IntsrceptorlTrap Grease �� <br /> Rec g FaaTdy Name: <br /> Re ,g�� , � <br /> CA <br /> T KG Re�io2d" Measunng Meffioa Used= Cordaueervalume(rPRequsrad)_ Percentage Flit pfRaqu;n : <br /> C,311ons <br /> El Pounds <br /> RegidaredTrmsportnrName: V c^� UehicrsDecW Number_ <br /> DnverNRacelvrng Fz a, yReptesenta5va Name(P?"rmt�~:JI <br /> Cq <br /> DcfiverSignabure^ Rew7nl ,I2epresenta6ve SBrIatun3 <br /> L 'd 16SL 'ON WdH : Z c �H 'S APN <br />