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9SL0 '°N W`d6S : 01 910 c ��W a�!1 pania�a� STATF.OF CALIFORNIA DEPARTMYNT OF FOOD AND AGRICULTURE Mc t,poultry arld Egg Safety B=oh 1220 N Street Manifest No:. Sac=ento,CA 95814 (91(5)900-5004 i 79-I24 (ESL 11112) - Manifest- Inedf ble Mtcheu Grease Trawspoft 4 Qj Instmeflons and Receiving Tac lin y Information l j I. 'A.compete Inedible Kiteheln,TGrea'se 01[�.G)Trawport Manifest for a load of IKG consists of this folrm, :,and all generator copies from MPESTonn 79-125(M= fest-Inedible Kitchen Grease Transport, Generator Worniatioan)'for generators .t cotitribiate IKG tci:16-lo$d. Alternatiyely,the IlKG transporter may use other forms that contain all]regni r'ed information. All forms in each manifest must ! 'have the same 4aniest Number. T ramporters nnust keep compieted-mai fests fbr.two pears. I Manifest Instructions: 9.The driver of the 1KG transport vehicle is responsible for entering all information on this form and on MPES Form 79- 12'5, Manifest-Inedible 1Gtehen Grease Transport Generator lnformatic n,.except for in the Deceiving Facility Represenfaiive and Generator Representative name and signature boxes. Ali entries must be in ink and legible- The !j driver must initial any corrections,to information already entered. ` 2. Enter all information in the form below for each load of IKG. Give one copy of the completed form to the receiving facifty atthe time of IKG receipt or mail or detiverthe copy tolhe receiving facility within-15 work.days. . �i. 3_ Enter the Manifest Number found at the top bf this form in the Manif�No, box.on the generator form(MPES Form 79- 125)for each generatorthat contributes to the load. All generator,forms.ftm generators where IKG was collected to make up the load must have the same Manifest Number as the attached Receiving Facility Information form_ ff 4. Give the generator copy(from WES Form 79-925)to the generator at the 6me of 1KG callection or mail or deliver the f copy to the generator within 45 calendar days. 5_Attach the generator farms (MPES Form 79-125)for all generators that,contributed to the load of IKG to this'Form. i Maintain this form and the attacheG generator forms for two years from the date on this form. l Date df lKC7 Recce t Time of IKG Receipt t Type of Used Cooling Oil AM Mme' 1KG- CrtCercegtorlrrap Grease A.6(miving FaaTrty Name.; Receiving Facility Addres5:..: ,. Lam- Tota!IKG-Received_ Imeasoing Method U--*d: CcrMmerV01uMe Qf Raquirad): Fer0entage Fist(lf Requinad), Gallons ,1 Pounds Registered Transporter Name_ (y k� Vehicle Decal Number_ s; Driver Name(Printf: Receiving Facility Representative Name(PTbTted): 3' Af� Lo t'�C' v Driver Signature: Receiving Facility Representative Signature:' 1! 9 d ti�6ti '�N AM : 1 l 9102 E A�vj