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09I "N AVH :0I LIH S add aUJ!1 paniaaa� STA-ER OF CALWOPMA DEPART1�MTT'OF FOOD AND A.GIUC` LTURE -- - Meat Poultry and Egg Safety B=rh lzzo rr st Manifest No:: L4 6 sacrmmcuw,CSA. 95914 (916)900-5004 'r �9-sem¢ �tins) �nif�st- Inedibl<citche-u Gress e Transport hw&ucfibns and Rece�Vm- TaciW Informat ioll VJ ..� —9 — 'A A complete Inedffile K tcheh_,l rea'se�MG:)Transport).Manifest for a load of 1KG consists of this form. ,and aIl generator copies from MPESTorm 79-125 (Manifest-Inedible Kitchen urease Transport, ' Generator Wormationy for generators that ZdUbtibute TSG tci.-tih.e"load Alternatrcetp,the]OKG . I t syaspoxter maty use other forms that cobtaft aH required mforma#on. All forms Soa each baanxfest xnusl eve the same 1V mi est Nnowlbei- TramVoice' wast keep eompieted-m=ffests-fof-two years Manifest Instructions: 1.7he driver of the lKG trdnsportvehicle is responsible for entering all information on this form and on MPES Form 79- :125, Manifest-lna6Ne{Cdchen G;r asa Transport, Generator lnfbi i r on,except 11or in thE Reraiving FacTiiy I Representative and Generator Representa$ve name and signature bcrxes. All entries must be in ink and legible- The !� driver must in►fial any con-ectionato h*fiormagon already entg r - .. 2 Enter,all information in the form below for each load of lKG- Give one copy of the completed form to the receiving. •FadW att-ie time of IMrecoipt or maYl or delver the copy tote recOving facifrEy wtthiri'f 5 workdays. 3. Enter the Manifest Number found at the Cop bf tris form in the Manikiii No.boxon the gene'rator fumi(MPES Form 78- f 12-5)for each generator that cont Mutes to thje joa4_ AD gener�torfomrs from generators where 1KG was collected to I make up the load must have the same Manifest Number as the attached RecaMing Facility lnformagon form 4. Give the generator copy(from MPES Form 7-M-125)to the generator-at the time of lKG collection or mail or deliver the copy to the rpeneratorwithin 45 calendar days_ _ } 5.Affach the generc-#rorms (MPES Fonn 79--125)for all generators that contributed th the load of IKG to this form_ Maintain this form and the attached geRer3torforms for two years from the date on this form. • I DBt a of ICG Rept Time of EKG Receipt TYPB of Q used coo"0.1 �- 2 Alin /Pn1J !KG: lnterceptorfTrap Grease k6ceFvo,q FaaTr(y Alamo: Receiving Fao�-yAddresa='""'" Total lKG Received: Meas'vring mamod Used. Corftainer Vo6mre(lf Reqz � ured)- Percentage Fig Of Requ-e . Gallons Pounds L Re3%t9Transporter Mane: Vehida Decal Number_ - Driver Name�-'TRR: I Rec;ivfng Facfy P-presentative a CP i b;iverSi_qrta6u� Rec®nnng�aaT resentative Signa>zu �I - c L 'd �L�L 'ON A00 : 0l L IH 'S 'add i;!