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$TATE OFCALTFQPJUA OSLO "N AV6S_ll 9l0Z 'ArA` auai1 pane DEPARTWI NT OF FOOD AND.A.GRIMTURE Meal;Poultry and Egg Safety Br=cta _- 20 N Street Manifest NO: ]21� Sacramento,CA 95814 (916)900-5004 79-124 (F-Z 1]!12) Manifest -- Inedible YAtchen Grease Tran-sport - jmstracdons and Receiviaa -FacpIty InformationL 'A,complete Inedible Mtchen bxesse VR�,G.)Transport Ma))ifest for a Load of EKG consists of.#his form } } and ah generator copies from AWESForm 79-125(Manifest-bledible Kitchen Grease Transport, f Generator Worniation)for generators-that cdmi-Mute JKG tai lhe•load. Alternativ ,the 1KG . 1 transporter may use other foar=s that contain all required information. AR forms in each manifest must f 'bane the same Manifest Numbelr_ Transporters must keep completed•maa;<ffests'for.two years. it Manifest Instructions: ;I 1.The driver of the iKG transport vehicle is responsible for entering all information on this form and on MPES Form 79- '125, Manifest-lnedUe Kdohen Grease Transport, Generator Information,' xcept for in the Receiving Facility Representative and Generator Representative name and signature boxes- All entries must be in ink and legible- The driver must initial any corrections.to informaUon already entered,, f 2. Enter all information in the form below for each load of IKG- Give one cppy of the completed form to the receiving f faci fty at the time of IKG receipt or mail or deliver the.copy to-the receiving facifitp within 15 workdays- .3. orkdays-3. Enter the Manifest dumber found at the top bf this form in the Manifest No. b8k.6n the generator form (MPES Farm 79- 12v�for each generator that contributes to tho]oad. All generator forms,from generators where IKG v�ras collected to make up the load must have the same Manifest Number as the attached Receiving Facility Information form. t ' 4. Give the generator copy(from MPES Form 79-125)to the generator at the time of IKG collection or mail or deliver the l oopy to the generator within 45 calendar days. _ 5.Attach the generator forms(MPES Form 79-925)for all generators that contributed to the load of 1 KG to this for _ Maintain this form and the attached generator forms for two years from the mdate on this form. I Date of IKG Recsipt Time of IKG Receipt Type of Used Cooking Oil �� lntanxptorlTmp Grease Receiving Fiacircty Names 1 Receiving Facility,Addru=--- Percentage FiII If Required); Total IKG Received: Mersuring Method Used: Corrtdinor Volume'(lf Required):" g ( 4 ed): Gallons \ Pounds �= t Registered Transporter Name Vehide Decd Number " } Driver Name(Prin#ed}' Rsce�ving FacUity Representative Name(Prmt£d)' I Driver Signature; 7 1 // Reserving FaaTriy 6�— Representatin+e Signature:' �I In r �1 1 f- - 6 AVH : ll 9lOZ ��A