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STAT;:o;=or;t.MORMLA 6090 '°N WdZ� :Z [ L [ N 'S -Upr ;W11 P;AI ;Dad DEPARIMOTT OF la'O.OD AND AGRrCULTD7 h Meat Poultry and Egg Safety Branch f� 1224--N Str- sc Manifest No.: RR— O q (9 Sai-=kenio,CA 95$14 _ (916)9005004 75-124 (J;SL I jag) , r Ms» est-Ined Ac.schen Grease Tr•,r porthisct ons and Receivxtg-Facility Information* 'A complete Jaedfbk Kftch.e7p rem,e VLK9 Transport Manifest for a load of IKG consists of this for } :.and ah geuea�or copies from 1VIPES Form 79-125 (ManYfest-rned�le Witchen Grease Transport, Generator Informafioaa.)•for generators t1tat cdi lxg�ute 1KG t6'tim load: A 1 -a1j!ye ,tte 1KG . , t mvsp otter may use other forms that contain aU regroored tuformaEon. All forms irx each manifest must 'have the same 11IanVest Nzimbear_ Transporters-must keep for-two pears. Manifest Instructions: I �I i 1_The driver of the IKG transport vehicle is responsible for entering afl information on this form and on MPES Form 79- '125, Man fest-lnedible Kltehen GreaseTrlansport Generator lnfbm:mtion,'.ezcept fi r in the ReceMng Facifty Representee and Generator Represent ffm name and sigrrzftre boxes_ All entries must be in ink and legible. The !3 driver must:inrr-ral any con ec ons.to lnformagoo already entered- -2- Enter all informafion in the form below for each load of lKG- Give one copy of the completed form to the receiving- f facTdy at the time of lKG recejp�or mail or deliver the copy to-the receiving facrTrty wfthin-15 work mays_ I IL 3. Enter theMaru"Fest Number found eithe top pYthis form in the Manifest No.box.On the generator form(MPES Form 79- p 125)for each generator that conte-butes to the load_ All generitarforms•f per generators where IKG was collected to maks up the load must have the same Manffla t Number as the attached Receiving Facility Information font. F 4; Give the generator copy(from MPES Form 79-125)to the generator at the time of lKG collection or mail or deliiver the copy to the genemtorwithin 45 calendar days_ _ 5.Attach the generabor forms (MPES Form 79-125)for all generators that contributed to tha load of IKG to this form. Maintain thle form and the attached geniarstorforms for two years from the date on this form. Date of lKG RamIpt !ung of 1 G l Q Used Cocking Of Typoof AM �� Arap G7aase ,= R6-7nri g Fgemy Names 7 i - FaciTyAddt Total lKG Rn-mived- GallonsMeasLung Method Used. Conta;narVoiume-QtFRequued): Percentage F$1 GfRequfredl; r - r. ❑ Pounds Regi en?cr Transporter N=a: / Vehicie Decal Number_ _ Driver Name - f = I RaCEi-E—g FauTV r-!Prasenfutive Name(Priabs -. DmrerSig ( nq Facgy r2epraser+tative Sigrratzu�' S1 I S 'd Z6L9 'ON — �._ Wd9LIE 5 upr