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1690 "N WdtiZ : 9 9lH 'cl 'Idy coil P;Al ;)ad <br /> D"ARTNJ NT SOF FOOD A M AGRICULTURE � <br /> Me-t,Poallvy and Egg Safety Eranch i 1 <br /> 1-220 N Street <br /> Manifest NO:: _ R3 <br /> Sagmmimto,CA 95814 = <br /> (915)900-5004 <br /> 79-124 OEeL 11112) <br /> Manifest-- Inedible Mtehen Grease TraYi,sport <br /> Instructions and Receiving'�+'araiYity Infor3aglft-flon rLF <br /> �• <br /> i <br /> complete inedx-ble Kitchen� x'e se��)Transport Manirfest for a load of JKG consists o thlis form J <br /> _and all generator copies from r4PES-Form 79-125 (Manifest-Y.nedz le 16tchen Grease Transport, <br /> Generator Wormation)for generators that'eoffiri-bate ISG tolhe load. Alterlaati�gy,the]KG. <br /> transporter may use other forms that contain all requked Wormation. Ali fomes in each manifest must 1 <br /> 'ha,ve the same-Manifest Number: Transporters'zunst keep cnmpleted•fua�iVests•for-two yearn <br /> Manifest instructions: <br /> 1.The driver of the IKG transport vehicle is responsible for entering all informabon on this form and on MPES Form 79- I� <br /> 125, ManiCeat-lnediNe Kitchen Grease Transport, Generator lnforrnafion,',f--xcept for in the Receiving Facility i <br /> Represzntative and Generator Representative name and signature boxes. Ali entries must be in ink and legible. The r� <br /> driver must initial any caorrections.to infor mflon already entered-- <br /> 2- <br /> ntered;2_ Enter all informefion in the form below for eaoh load of IKG. Give one copy of the completed form to the receiving <br /> ftcirr'fy at the time of IKG rec4alpt or mail or deliVer the copy to-the receiving facTriy within-15 workdays_ <br /> �i <br /> =3_ Enter the Manifest Number-found atthe'topbfNsforrn in the Manifest No_toxon the generstortorm (MPES Form 79- <br /> 125)for each generator that cQntn'butes to th>l~Ioad_ 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(from MIPES Form 79--925)to generator enerator atthe time of lKG coilecfion or mafl or deliver the F <br /> copy to the generator within 45 calendar days_ <br /> E <br /> 5.Attach the generztorforms(MPES Form 79-925)for all generatdrs-that contributed to the load of IKG to this form. �f <br /> Maintain this form and the attached genoratorforms for two years from the date on this form. 1 <br /> i <br /> D--fiL%of TKG Receipt lane of lKG Recce Used Cooking 07 } <br /> J/ <br /> .� r , � TYPO°r ❑ i,/ (O lnteme OaTrap Grease <br /> i <br /> R--ceivmg Favi Name_ <br /> Rem--ing FONT rAddt ,c w:"' <br /> Ir <br /> Total 1KG F2--Mived- Measuring me#fiod Used= Container VolUme�(W Reguin2d): Percentage FiII(rf RequirEd): <br /> c2:'-Gallons <br /> Founds <br /> Registered Transporter Name: Vehicle Demi Number_ <br /> Driver Name(Printed)_ Reu&Ong F'acifRy Represar&-i ive Name(PrintEcl)- <br /> priverSignablre Ren�wing Fa sty Repress Signature: �( <br /> t 'd 6Z 'ON Wd36 : 9 9102 <br />