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STA-MofCAL>FORMA 6090 '°N Wdl0 Zl L101 'S .upr aW I i Paniaaa <br /> bJKPArRTMRWT fQ.F FGOD AMID AGRICULTURE h <br /> Meat,Poniny and Egg Safety 13rmch <br /> 1220 N Str= Manifest No.: R R- dpi r <br /> Sacram=O,CA 95814 <br /> (916)900-5004 <br /> 79-224 oRm 11/12) <br /> Alani&ICs - edible K tchexk Grease 'T rarisport <br /> l 0%t- t- t_ - <br /> IustJrue bns and Receiving . aeffity Wormati.on � kk <br /> complete Teed Ze chen ease�Tr��port des$for a load of 1K.G consists of tbSs form f <br /> ,and all gauerator copies from AH EESTOrm 79-125 (Mab_MA-TnedffiIe Mi h n Grease Trawport, � <br /> Generator laforuiation)for g Aerators fimt cda&nute l:G td:thvload- Alternatively, the ING � <br /> travzporter may use other f>Drms that conte an required jlQforbaai%on. AIIIf6rDxs You each manifest mast <br /> pave the Same M�nffest Nz�mber. Trawpoi ters•muA keep c"lefe,d mariffests for-two years. <br /> Manifest Instructions: <br /> 1.The driver of the XKG transport vehicle is responsible for entering all irlformaBon on this form and on MPES f=orm 79- <br /> J <br /> 125, Manlfbst-Inedible IGIz~hen Grease Transport, Gerieraivr lnfurrF►aGon,'�xcept for in the Recei nq FacrTity <br /> Representative and Generator Representahva name and signature boxes_ All entries must be in ink and legible_ The <br /> driver must initial any corrections.to information already"red- <br /> .2- Enter all irtformaffon in the form below for each load of IKG_ Give one copy of the completed form to the receiving- , <br /> facTti y atthe time of JKG receipt or mail or deffiverthe copy tothe recgking facilftywflhin-15 workdays. <br /> _3_Enter the Man"rfest Number found at file fop rsftiiis form in the Manifest No_ box.on the generator form(MPES Form 7;o <br /> 125)for each generator that contributes to thp load. AIX from generators where IKG was collected to F <br /> make up the load must have the same Manifest Number as the attached Receiving Facility Information form f <br /> 4. Give the generator copy(from MPES Form 79-125)to the generator atthe time of 1KG collection or mail or deliver the <br /> copy to the generatorwithin 45 calendar days- <br /> 5.Aftach the gener4arforms (MPES Form 79-125)for all genelzdnrs that contributed to the load of IKG to this form. <br /> Maintain this form and the attached generatorforms for two years from the date on this form. <br /> • - I <br /> Date of 1KG Receipt Tirna of IKG Rsce;pt r—�Type of Used C.;d g CU I <br /> (� Q <br /> J PM IKCtr Intn=pt0rMzp Grease ;r <br /> ReQ4Vbg Faculty Namra <br /> n <br /> LAE IL7 <br /> Receiving FacrTrtyAddre�°""'"` <br /> Total IKG Rsceved Measurrng Mdfled CoriWLnervolume•(ifRagturad)- Percentage l-- 1 gRequired)- <br /> TOQallons <br /> /2-o a - por,,, CrA1,` ( Ado Ca3F Y6 <br /> R ergl Tr ns1?o Velirde Decal Number_ _ <br /> ba� <br /> I ` <br /> Dmrer Name(Printed)- RawMng FacaTdy Rapresen>u6ve r`tarno(Prmte�= <br /> 1 <br /> tn <br /> Driversigrr c R g E`a_Tey Repressrrl*ve Sjgn <br /> I'. <br /> ii Z 'd Z6L9 'ON WdH : Zl LIN 'S 'u"r <br />