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OF ,� --6090 'ON ME : l LIN 'S 'upr awil pania);� IA i � <br /> DFTAMMEDU OFFOOD AND AGRICULTUR_ F _ h <br /> Mead Poultry and E&Se vV Branch _ Man if2S f No. <br /> 10 <br /> 1220 N Sn eeL <br /> Sa"ua=to,CA. 95914 <br /> (916)900-5004 � •q �l�j �/� � <br /> 79-V-4 (Fsc IIA2-) <br /> Max fust-Xue&lble Ritcheia Grease TZ. -t <br /> J-utruefiblis and Receiving F�ca�ZLy Luforma iio]� r� <br /> yr 1 <br /> Z&complete TaedWe.XU&e� ease Transport 1Vlanifes for$load of IKG wbsis`ts ofihiis form <br /> -_,and aU generator copies.from AUTS Fo m 79-125 (Manifest-Inedflle Irffcb e3n Grease Trm sport; <br /> Generator Ymformaa-biox>t7 for gcrierators that cdixfrn`6t to IXG td:the-loa& Alteunatively,.the ISG , { <br /> transporter xray use other forms that coxdni n an reed to Irma-dom All foxxas in each manifies-t must E <br /> 'hare 1%e same At.Wai6st mE ber_ Trsnsporteri xanst Deep coMpI�-ffianxests fpk-two years. { <br /> Manif=est Instructions: <br /> 1.The driver of the IKG transport vehicle is responsible for entering all information on this form and on MPES Form 79- 1 <br /> :126, Manifest-Inedible kCfthen Grease Transport;Generator Information;zxeept:for M the Receiving FaciTiy i <br /> Repres-pr ve and Genera>bor Representative name 2nd signature boxes. All entries must:be in ink and legible_ The !3 <br /> driver must inial any correctaons.to InfbrnTa9oa already entpred, <br /> 2. Enter all irdorrna5on in the form below for each load of IKG_ Give one oppy of the completed form to the receiving. <br /> faoTTdy at!jhe time of IKG rec6ipt or mail or delver the copy to-the receiving facility within-15 workdays. � <br /> 3-Enter the Marirfest Number found attire tap;Dfthis form in the Marirfest No.b(Sx6n the generatDrform(MPES Form 79- <br /> 125)for each gerle[ator that rr�ntrl�utes to if�eload_ A"generatorfonm-frpm generabots where IKG was collected to <br /> makeup the load must have the same Manffb E Number as the attached Receiving Facility Information fbnn. I <br /> 4-Give the generator copy(from MPES Form 79-125)to the generator at the time of IKG collection or mail or deliver the <br /> copy to the generatorwithin 46 calendar days. 1 <br /> I <br /> 5-Attach the generabmrforms(MPES Form 79-125)for all generab&s that cont ibuted to the load of IKG to this form- <br /> Maintain this fonn and the aifached generatorforms for two years from the date on this form. <br /> Dob�of IfCG R C6ipt Tn of IKG Receipt used ConWg Oil ! <br /> Type of AM FM IKG Inrterceptorlrrap Grease =II <br /> f <br /> F�rvmg Faa•IIty Names <br /> Rung Facffty Ad&vs "t <br /> Total IKG Recaived- Measuring Method Used: Corrlainer olams'(lf RaquirecD: Percentage Fip(if Required)_ <br /> Gallons <br /> i <br /> m p pounas <br /> Registarkl Traruporier Nacre: Vehide Decal Numbei_ - <br /> 1140 2,56�e� - <br /> C) ver Nino(Pri}rL . - ROC6 fig FacaTdY PLe O SZDU va Name(Print : j <br /> i <br /> Driversigrr ,rte - Reserving r�oLiy RepressnbffvaS"pnmbrrr-' { <br /> I I 'd 1E9 'ON WdH : ZI LIN S 'upr <br />