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STATE OF GALIFORMA . <br /> --6090 "N Md :� I LIH S 'upr 'awIJ paniaaa� <br /> DEPARTMENT QF FOOD AND <br /> Meal;Poult!;yand egg Safety Rr=ch _ ManlfeS$V No;: R RTC) I <br /> 1220 N Sint <br /> saL7,-mento,GA 95814 <br /> (916) 900`5044 <br /> Manifest--Ynes Bible-ICrfchen Grease Transpoxt - v123 <br /> Instractio s and Reed7ingT cility Information <br /> 'A complete I-aedib]e Bitchen�reaseDK9 Transport Manifest fox-a load of IKG consists o thus tom <br /> ,and aU generator copies mom MPES°Form 79-125 (Manifest-Inedible-Kitchen Grease Ti-a sport, <br /> Generator Information)for generators thst ibft t ribMe JKG to:the load. AUexnativetp,the IKG <br /> transporter may-use other formas that contain.AU Iregmored inforinAgon. A31 foams in each manifiz*E uL-n t <br /> 'have the SAM a Ma>olifest Naber. Transpo3i-ters'M st keep cumpleted-manifesrts-fpt-two years. � <br /> Manifest Instructions: <br /> 1_The driver of the IKG transportvehide is responsible for entering all lnformaiion on this form and on MPES Form 79- ;l <br /> 125, Manifest-1ned-Ne Kitchen Grease Transport, Generator lnfomnad ri'ex pt for in the Receiving Facility LII <br /> Repriasentative and Generator Representative name and signature boxes_ All entries must be in ink and legible_ The !� <br /> driver must inigal any corrections to infonrra5on already enured; 3 r <br /> 2 Enter all ir>formation in the form below for each load of IKG_ Give one copy of the completed form to the receiving <br /> facrTti y at the time of 1KG reci�ipt or ma71 or dedrver the copy to-Me recgMng facTrty wrthiri-15 wor k.days. 1 <br /> :3_ i=nter the Manifest Number found atthe top bf this form in the Manifest No_ box.on the generator form (MPES Form 79- <br /> 125)for each generatC7rthat contributes to th—joad_ All generatarforms•from g�neratols where IKG wes collected to <br /> make up the load must have the same Manifest Number as the attached Receiving Facility Informa4o <br /> n fbrrrL F <br /> mak- aive the generator copy(from MPES Form 79--125)to the generator at the time of IKG collection or mail or deriver the <br /> copXto the generator within 45 calendar days_ _ <br /> I <br /> 5_Attach the.genel-,torforms (MPES Form 7'3-125)for all generators that contributed to the load of UKG to this form. I <br /> Maintain this form and the attached generatorforms for-two years from the date on this form_ <br /> Dabe of IKG R.ncaipt Trina of IKG Receipt: T of r-1 Used Cooking Oil�r� I_1 j- <br /> / � F'M IKG Irrtsnmptorlrrap Grease <br /> z4g Eoo�e� 1- . _7/_�-F <br /> FZ6celmmg Fac�Tily Name: <br /> o e-7 <br /> ' R�vQIg Fa�if-yAtJdr�ss:m""` - - <br /> 22- 7 P-A , <br /> Total IKG Removed Measuring sed <br /> Gallons Method UConInIner oI=a'(If Required)= Percentage FSI pf Required)_ <br /> ' <br /> �7© V ❑ Pounds 'c4 �( <br /> Registered Transporter Narn� VehicIe Decal Number. - <br /> Driven-Name(Printed): / tvFng FacaTdy Repres��Name(Pnl7ted)_ <br /> Dm eT_12 9rrahrre_ ng Facffldy Represerrtafiva Signa:' 7' <br /> l( <br /> 71�� <br /> 6 'd Z6L9 'aN ME :E l LIN S ups <br />