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-` L901 '°N Ad6S : l 9l0Z 'S un awi1 pani MTE OF CALIFORNIA DEPARTN N'T OF FOOD AND AGRfCLTi,TURE !� Mea4 Poultry and Egg safetySramch manifest No:: 1220 N Street sa,ct`amenm,CA 95814 ` (916)900-5004 l 79-124 (Fst 11/12) Manifest - Inedilke Kitchen Grease Transport Instruclaons and Receiving-Fac' 'ty Information 'A complete Inedible Kitchen grease� iG)Transport Maw fest for a load of EKG consists of this form r ...and all generator copies Brom MPESTor'm 79-JL25 (Manifest-Inedible JDtchea Grease Transport, J Generator Information)for generators'that-edi(tribUte IKG to'the`load. Alternatively,the IKG -transporter may use other foams that contain all required imformAtion. Allforms in each manifest must i -have the same Manifest Number. Transpoiters'mnst keep coy Pl6ted-manilfests for-two years: � Manifest Instructions: 1.The driver of the IKG transport vehicle is responsible for entering all infomration on this torn and on MPES Form 79- Facil :125, Manifest-Inedible Kitchen Grease Tf'ansport, Generator Informaiien,.except for in the Recernn g ►tY ii Representative and Generator Representative name and sigrTature boxes. All entries must be in ink and legible. The J driver must initial any corrections.tu information already entered. 2. Enter all information in the form below for each load of IKG. Give one copy of the completed form to the receiving facik at the time of IKG recbipt or mail or derver the copy toifie receiving facility within-15 work-days. 3_ Enter the Manifest Number found at the top V this form In the Manifest No.box.on the generator form (MPES Form 79- 12.5)for each generator that cont-lutes to the load. All generptor forms#ram generators where 1KG was collected to make up the load must have the same Manifest Number as the attached Receiving Facility Information form. from MPES Form 79-125)to the generator at the time oP IKG collection or mail or deliver the 4. Give the generator copy( j copy to the generator within 45 calendar days. _ 5.Attach the generaivrforms (MPES Form 79-126)for all generators that.contributed to the:load of IKG to this form. Maintain this form and the attached generator forms for two years from the date on this form. t Date of XG Receip Time of IKG Recalpt Type of ❑ Used Cooking Oil O�- PM IKG: ra/'Interceptorfrrap Grease Racetving Fa Name:/ � � . , I ReceivtIg Faaiity Addrn;!P'- — Z2 god - 7otal IKG Received: Measuring Method used: Container Volume'Qf Required)' Percentage Fit(If Required)' Callous :� 1—I Pounds Registered Transporter.Name- ((( 111 Vehicle Deml Number. 7� Z2— t 'S ISEL�:;s Rv r Name(Printm*; Roving Facility Represerea�ve Na me(Print°d)' -F��I LON 6 P 1-E briver Signature Receiving radlity Rap rEse tfve 51grature'' 6 'd LLS '°N WdEo :Z 9lH 'S ''ny