Laserfiche WebLink
sTA ox c tio>r�a "~ OSCO '°N 06� Ol 9lOZ t�W auli1- pin i <br /> DEPARTIVNI'iaF FQOD ASND AGRICU�'X'L�RE (,}} <br /> NIS Poultry and P,-,-Safety Srazch 'I <br /> 1220 N Street Manifest anifest No:;'�'� <br /> . (� <br /> Sacramento,CA 95814 G <br /> (916)900-5004 r <br /> 79-124 (Est 11/12) <br /> Manifest - JiaediJ Je Kitchen Grease Transport -- f <br /> Ynstrucfions and Reeeiviug•Faic4ity Nformation �1 <br /> 'A complete nedi` Ie Kitc�teri re see (��)Tr txsport Manifest for a load of�G consists of tWs form I <br /> anal all generator copies from WFN'Torm 79-125 (Manifest-ineditble Kitcb,eln.Grease Trawport, , <br /> Generator Wormation)for generators that contribute MG to:the load. Altelrxl!stirvely,the TSG <br /> transporter may use•other forms that contain all required information. AR forms in each manifest must <br /> 'have the same Manifest Number. 'Tira>rispoiters must keep campteted-manifests-for.two years, � <br /> Manifest Instructions; <br /> 1.The driver of the lKG transport vehicle is responsible for entering all information on this form and on MPES Form�Y 79- <br /> Facility <br /> 1 <br /> 125, Mintiest-inedible Kitchen Grease Transport, Generator Infm <br /> oration, accept fiat in the Receiving <br /> Representative and Generator Representative name and signftre boxes_ All entries must be in ink and legible, The !� <br /> driver rnust initial any correctionsto information already entered; <br /> 2. Enter all information in the form below for each load of IKG. Give one copy of the completed form to the receiving <br /> facilrtjr at the time of IKG receipt or mail or detiverthe copy to-the receiving fa ffity within 15,workdays. <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- <br /> 125)for each generator that contributes to the load. All generator forms from generators where IKG was collected to <br /> make up the load must have the same Manifest Number as the attached Receiving Facility Information form_ <br /> 4_ Give the generator copy(front MPES Form 78-12.5)to the generator at the time of IKG collection or mail or deliver the <br /> copy to the generatorwithin 45 calendar days. <br /> 5_Attach the generltor forms (MPES Form 79-125)for all generators that contributed to the load of lKG to this foram_ <br /> Maintain this form and the attached gene-ratorforms for two years from the date on this form. (I <br /> Data of XG Receipt Time of IKG Receipt Tyj�.e of Used Cooking Gil <br /> A P <br /> IKG. lnteroep#orlTrap Grease <br /> Receiving Faarrty Name: •. � <br /> Receiving'Facility Aiddre5e <br /> rt e C7 . <br /> Total 1KG Received: Maasuring Meth Used: CortiBiner Volume'(If Required}: Percerta�e Fill Of fZcquired}: <br /> © Pounda <br /> Registered Transporter Name!: Vehicle Decor Number. <br /> 3 <br /> Driver Name(Printed: Kacar ing F-atility Represer�ti've,r�{arrie Printt cI)• <br /> DriverSignatur = Receiving Paalrty /Retative Sbnnatturef { <br /> ll 'd ti2WcN Wd�O ll OIOZ �pW <br />