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S-WM 07 CA11?O1Ra4AL901 '°N-Wd6S l -9lOZ= 'S 2ny_awil Pani ;°ad: <br /> DEPARTMENT OF FOOD AND AGRIC1M11r(M <br /> Meal;Poultry and Egg Safety Bunch f <br /> . 12-20 N Surest Manifest No:: [; <br /> Saarame?ato,CA 95314 <br /> (916)900-5004 <br /> 79-124 (Est I I/1z) <br /> Manifest- Inedilke Kitcblen Grease Transport _ L <br /> Instructions and ce' <br /> - _C1t;�ns Re ruing Facility Information <br /> 'A complete Inedible 70tchen re9se fKG)Transport Maiffest for a load of 1XG consists of this form <br /> ..and aIl generator copies from MPES',Form 79-125 (Manifest-Inedible Kitchen Gxe2se'TransVor4 ' <br /> Generator Liformation)for generators that coutlnirbnte I KG'to.'the°load: Altern.stFv ,the IKG <br /> transporter may use other forms that contain aIl required Worma#on. All forms in each manifest must E <br /> hope the same Msni#est Number. Transporter-,must keep completed'mahffests-for-two years. <br /> Manifest Instructions: <br /> 1.The driver of the IKG transport vehicle is responsible for entering all infomration on this form and on MPES Form 79- <br /> .125, Manifest-Inedible Kitchen Grease Transport; Generator lnfomaation,except for in the Receiving Facility !I <br /> Representative and Generator Representative name and signature boxes. All entries must be In ink andlegible_ The !I <br /> driver must infial any correctionato information already entered. <br /> 2. Enter all information in the form below for each load of 1KG. Give one copy of the completed form to the receiving <br /> facility atThe time of IKG reobipfi or mall or defiver the copy to-the receiving facility within-16-work-days. <br /> L <br /> _3_ Enter the Manifest Number found at the top bf this form in the Manifest No.box.on the generator form (MPES Form 79- h <br /> 125)for each generator that contributes to the toad. Al g(�neratorforms,from generators where lKG was collected to <br /> make up the load must have the same Manifest Number as the attached Receiving Facility Information form. f <br /> 4_ Give the generator copy(from MPES Form 79-125)to the generator at the time of 1KG collection or mail or deliver the f <br /> copy to the generator within 45 calendar days. <br /> I <br /> 5.Attach the generator forms(MPES Folin 79-125)for all generators that contributed to the load of 1KG to this form. <br /> Maintain this form and the attached denerator forms for two years from the date on this form. <br /> Date of KG Re-M-pt lane of IKG Recuipt T Used Cooldrng Oil e <br /> Type ' <br /> 7_ _ /j1 'J AM PM IKG: tercaptor/Trap GraasE <br /> P_�g FaaTity Names <br /> Receiving FaaTdyAd*u5e.­ ' <br /> l2 AJ, ` v, C ,r <br /> Tatal IKG Pamivad- , , /_ Ilona Measuringbliod Used: Container Volume'(If Required): Fercantage Fill Of R,quaEd): <br /> /✓tea / `� � s d �. <br /> Pounds op <br /> Registered Transporter_Name: Vehlele Decal Number_ <br /> Driver Name(Printed): Receiving Facility Ropresentative Name(PYakGcQ: Y <br /> r� <br /> LOA)_6P� <br /> DriverSignatu Receiving FacT3 ty Representative Signature.:' <br /> �1 <br /> ti 'd LLS '°N WdZo : Z 9l0Z 'S '2nd <br />