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- L901 '°N M S :S 9 0 'S nd ;LU II panlana� STA OF CALIFORNIA r �� D"ARTWNT OF FOOD AND AGRICULTURE Meat,Poultry and Egg safety Branch Manifest No.. 1220 N Street � Sacramento,CA 95914 (916)900-5004 ' 79-L24 (Est 11/12) Manifest - Xn,edible K tche-n Grease Tra.iasport L Instructions and Receivi Facility l(nformation l 9,complete Inedible Kitchen. re pe G.�.Transport Manifest for a load of IIKG coiaksts of this form and all generator copies from MPES'-Foxm 79-125 (Manffest-Inedible Kitchen Grease Transport, Generator Wormation.)for generators that cdzitribute IKG to'the•load. Alternatrvely,the IKG , transporter may'ase other formas that contain all required h3formation. All forms in each manflfest must 'have the same Manifest Number_ Transporters must keep completed'mani£est-%for two years, f Manifest Instructions: 1.The driver of the IKG transport vehicle is responsible for entering all information on this form and on MPES Form 79-- :125, Manifest-Inedible K1tEhen Graase Transport, Generator Informatlon,'.except for In the Receiving Facility i� Representative and Generator Representative name and signature boxes. All entries must be in ink and legible. The i driver must initial any corrections,to information already entered; G 2. Enter all information in the form below for each load of IKG. Give one copy of the completed form to the receiving faciny at the time of IKG recaipt or mail or deliver the copy tothe receiving facility withinJ5 workdays. f 3. Enter the Manifest Number found at the top Of this form In the Manifest No. box.on the generator form(MPES Form 79- '12�for each generator that contributes to the load. All generator farms from generators where IKG was collected to make up the load must have the same Manifest Number as the attached Recelving Facility Information form. i 4. Give the generator copy(from NIPES Form 79-125)to the generator at the time of IKG collecl�on or mail or deliver the copy to the generatorwithin 45 calendar days. _ 5.Attach the generator forms (MPES Form 79--125)for all generators that.conb ibufed to the load of IKG to this form. t Maintain this form and the attached generator forms for two years from the date on this form_ � 'I Date of FKG Rsoeip Time of IKG Receipt T used Cooldng Oil El 1,21 >AM M IKG: Inten�ptorlrrap Grease Receiving cirfiy Name: I. Riving Faa�ityAddress"�",.,; I� Total IKG Received: Measuring Method used: Conlainer olume'of Required): Percentage Fill(if Required): : allows Ej Pounds l z _ aegistared Tranorter.Name: / spVehicle Decal Number_ 74 2 Driver Name(Printed): Receiving Facility Reprasen ative Name(Prirtta-d) I i /),0_<"—, ,) DmrarSignaturrw Receiving Facility Repress tNa Signature' / ff L 'd LLS '°N AdZo :Z 9 [0Z 'G nd 1''