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L690 "N Wdti� :9 9102 ;W1 j pania);� STA i E 01:CALIFORNL4 +� DEPARTMMNT OF FOOD AND AGRICULTURE (r Meat,Poultry and Egg Safety Stanch . 12--C)N stmt Manifest No:: S---m-mo,CA 95914 (915)900-5004 79-124 (ESS I3/12) c Mau f-est- InedilAe Kitchen G•xease Tr.a•xltsport Instructions and Receiving For ty Information 'A complete Inedible Kitchegll; Case G)Transport M-ILWest for a load of IKG consists of this form ..and all generator copies from MPES;Form 79-125(Manifest-Inedible Kitchen Grease Transport Generator Information.)for generators that contk:ffiiite IIKG tci'the load. Alternstively,the IKG transporter mai'use other forms that contain all required information, All forms in each mauifest must 4 'have the same Manifest Number. Transporters'must keep completed-in- wi fests fort ro years. Manifest Instructions: f� 1-7he driver of the IKG transport vehicle is responsible for entering all information on this farm and on MPES Form 79- .125, Manifest-InediNe IGtchen Grease Transport, Generator lriforrnaddn,,except 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 correct onato,information already enlpared; 2. Enter all information in the form below for each load of IKG. Give one copy of the completed form to the receiving k facility at the time of 1 KG recOipfi or mail or definer the copy to-ft receiving faciltty within-15-workdays. 3. Enter the Manifest Number found at the top' this form in the Manifest No_ box_6n the generator form(MPES Form 79- ,125)for each generator that contributes to the load. All generatorforms from generators where IKG was collected to make up the load must have the same Manifest Number as the attached Receiving Facility Information form_ f 4. Give the generator copy(from MPES Farm 79-125)to the generator at the time of IXG collection or mail or deliver the copy-to the generator within 45 calendar days_ 5_Attach the generator forms (MPES Form 79-125)for all genera 6rs that contributed to the load of IKG to this form. Maintain this form and the attached generator forms for two years from the date on this form. � e I Tate Of 1KG Receipt Tme of IKG Receipt i Type of ❑�Cooking Oil i. AM PM 1KG: �❑ Interceptor/Trap Grease Receiving Fararfty Name: ?{ Receiving Fac%Trty Address-----` Total IKG Received, Measuring Method Used- OdntainerVolume'(lf'Requined); Percentage Ru(if Required): rLJ Gallons Founds Registered Transpnrter Name_ l Vehicle Deal Number= D&er Name ring_ Re4eauing Facility Representative Name(Printed): ----------------------------- Driver Signature: �1 Recti" acirV Reprawntaffve Signature:' �l ;� --�L d 6 Z 8� N =_�� • �.��.�-_�'..��...�ft� Ad H :9 , 10 Z �l d �