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STATE OF CALIFORNIA t901 'oN=Wd6S : 1 �910Z. 'S A,1V=1wil paniaaad 1 DEPART:i M OF F'O'OD AND AGPJCULTUREh Meaf,Poultry and Egg Safety Branch 3220 N Street M.a n fest No. 02 CI S Sacramento,CA. 95914 � (916)900-5004 r _ r 79-124 (EsL 11112) Maze - Ineth-ble Kitchen Grease Transport Instr eflons and Reeei�g-Facil Information � 'A complete Znedble Mitchen•grease O)Transport AUn>ifest for a load of 1KG consists of this form __and aR generator copies from N TES Form 79-125 (M-uffest-Inedible Kitchen°Grease Transport, ° Generator Infornlatioll)for generators that EdAtt ibute.IKG*d:thw1oad: Alternatively,the WG transporter may use otbtelr forms that containall required informsfion. AA-forms in each man fest must 'brave the same Manifest Number. Transporters'-must beep cQmpleted-imnifests fo]•I- YO pears. Manifest Instructions: 1_The driver of the IKG transport vehicle Is responsible for entering all information on this form and on MPES Form 79- 1 25, 9-125, Manrfest-InediNe Kitchen Grease Transport; Generator Info,,rZ•ation,'-axceptfor in the Receiving Facility Representative and Generator Representative name and signdture boxes. All entries must be in ink and legible. The driver must initial any corrections.to information already entered: t 2. Enter all information in the form below for each load of IKG_ Give one copy of the completed form to the receiving faci7rty at the time of JKG receipt or mail or deliver the copy tolhe receiving iacititywithin-i:7 work.days. • �E __3. Enter the Manifest Number found at the top pf this form in the Manifest No_box.6n the generator form (MPES Form 79- 125)for each generator that contributes to the.load. All geneu&To forms•fmrn generators where IKG was collected to make up the load must have the same Manifest Number as the attached Receiving Facility Information form_ f 4_ Give the generator copy(from MPES Form 79-125)to the generator at the time of IKG collection or mail or deriver the cop)to the generator within 45 calendar days. _ I 5.Attach the generator forms(MPES Form 79--125)for all generators that,contributed to the load of IKG to this form. I Maintain this form and the attached generator forms for two years from the date on this form. ll Data of IKG Reoelpr Time of KG rpt Used Cooking Oil / Type of i 7 IKG: InteroeptodTrap Grease ( 1 �I�� i Receiving Fad'rlty Name: Receiving Facility A&kas " -- 6 Total XG Received: Measuring Method Used: Corttainer Volume'(lf R uired)_ Pe=ntage FSM Of Required)_ �b�IIQns �: Pounds Regiered'TmnsporterN=e: Vehide Decal Number. e S 7X Drn/er Name CPrird): Receiving Faa1$y ReprasanNs Name(Printed): DdvswSignature: Reci'mng�<ia"lity Reprasent ibve Sbrratuma' 7 f 9 'd LLS '°N MO :Z 9102 S '23nd