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060 "N NdH:: 9 [0Z cavil pania3ad STA_M OF ICALIFORNIA 1DM> .12 17 A nF FOOD ND AGRICULTURE Meat;Po and E 9 Safety Brooch leo x Manifest No Q a � Sacramento,CA 95814 � (912)9o�so� Manff,e,st- Inedible Kitchen Grease T> aim' 'Sport lusbmetilons and Reeeivir;,,,•Facphy Yuformation 4 comple#e le Kitchen 6resse- MG)Tmnyort MAnifest for a load of MG cou sts ofthis form Jt and aII generator copies from MPFS''Form 79-725 (Maaif'est-hwdi"ble 7KI-tchen Grease Transport, Generatl r TjiforAaation)for generators fhst coftfribWe IKG to:the-load: Alterna#r,e ,the ISG , transporter may nse other forms that contain all required infon nation_ AR fori ms icor each manifest mast• have the ssm a B at t est N amber. Transporters mast keep completexl maxi�ests for-two years. Manif t Instructions: :I 1.The d er of the IKG transport vehicle is responsible for entering all lrrfonrration on this form and on MPES Form 79- :123, Manifest-Inedible Kitchen Grease Transport, Generator Infonsmtion,.exceptforin the RemMng Facil"rty Representative and Generator Representable name and sigh*tur'e boxes. Al entries must be In ink and legible_ The !� driver mul t initial any corrections to information already entered; 2 Enter all Information in the form below far each load of IKG_ Give one copy of the completed form to the recelving ' foci fty at The time of IKG rec,4Apt or mail or deliver the copy to-the receiving•faciCrty within-1&work.days_ l 3. Enter the ManM?fest Number found atthe top bf this form in the Manifest No. box.on the generator forrn(MPES Form 79- 925)for each generator that contributes to tiptoed. All generatorforrris,frorrl generators where!KG was collected to make up the load must have the same Manifest Number as the attached Receiving Facility Information form_ 4. Give the generator copy(from MPES Form 79-125)to the generator atthe time of 1KG collection or mail or defier the copyto ttie generator within 45 calendar days. _ f 5_Attach�fhe generator forms(MPES Form 7-0-125)for all generators that,contributed to the load of lKG to this form. i Maintain this forrrrand the attached generator forms for two years from the date on thls form_ _ t Dale of IKG Rec4l; TSme of(KG R�ipt: l TYMQf E] Used CoolarLq OB i C/ AnA PM IKG rntercap2orYrrap G7ease Receiving FaaTrly Name: - l Rece�FaaTrtyAddrus&--- .� Total IKG Received: Gallons Measuring Method Used Con7ainerVolume'(If Requ� _ Pen�nbge Flt I(If R Ired): rA Poundsa ._(A1f1ra&j :�: r R - Transporter Name ricla Decal Number_ _ l)dverN2m'e(Prix Lam: ReCQrving FdpTrty RepnesentaKe Nam®(Printed): pal Driver Sigrrafr ire: �p 'ng Ra TV Raprasarttatfve SigrraWre:' :if t L 'd 9Z '°N Nd�E :t 9l0l � l 'Inr P►