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STA'IBOFCALtMENIA 19�O "N Wd6l :E 9[H '6 'qad quail pania�a <br /> pEPARTMKNT QF FOOD AND AGRICULTURE — � {T <br /> Mea4 Poultry and EW Safety B�zmch <br /> 1220-N streek Manifest No.- <br /> Sacramento,CA 95814 <br /> (416)900-5004' <br /> F <br /> 79-124 (Esi.11112) <br /> alralifest—Inedflk Ydtc- hen Grease Traiispor t } <br /> Instm . ons and Reeeivi —Fac�W Information � <br /> =A comlrlete Tnedil`ble Kitchen- TeaseG�Transport IVlauiest for a load of IKG consists of this form <br /> ,and all geuerator copies from MPESTorm 79-125 (M=ifest-Inedilble J iRchen Grease Transport, � <br /> Generator Ii!#"ormation)for generators that cdntribdte J G to thvload, Axternat"ly,the IKG . <br /> tranVorter may use other forams that eontaim ail required Wormatio�a_ AR forms in each mauifest must I <br /> 'have the same Manitest Nnmbe�r. Tramsportexi'must lwep c4mpieted ainauicfest., 0r.tfP0 years. fi <br /> Manifest Instructions; <br /> 1.The driver of the iKG'transport vehicle is responsible for entering all information on this'Form and on WES Form 79- <br /> :125, MarirFest-Inedil3le Krtctten Grease Transport Generator Infarrnation,-except for in the Receiving Facility <br /> Representative and Generator Representative name and sig[tsture boxes_ All entries must be in ink and legible The <br /> driver must initial any corrections,to information already entered; <br /> 2. Enter all information in the form below for each(orad of I KG. Give one appy of the completed form to the receiving � <br /> faci[ity at the time of iKG reo,6ipt or mail or definer the copy to-the ren eWmg facility within 15.work.days_ <br /> 3. Enter the Manifest Number found at the top bf this form in the Manifest No. box.on the tgenerator farm(MPES Form 79- <br /> -126)for each generator that corlWbutes to the load. All generator forms.from generators where I KG was collected to <br /> make lap the load must have the same.Manifbat Number as the attached Receiving FaGillbj Information form. ' <br /> 4. Give the generator copy(from MP ES Form 79-125)to the generator at the time of lKG collection or mail or deliver the t <br /> copy to the generator within 45 calendar days. i <br /> 6_Attach the generator forms (MPES Form 79-125)for all generators that,contributed to the load of IKG to this form_ <br /> Maintain this form and the attached generator forms for two years from�he date on this form. <br /> aln of KG R_7 <br /> _ ipt Torte of IKG Receipt Type <br /> of L] Used Cooking Oil E <br /> J 'PM ZKG: lntenpt4rfrr2p GreSe <br /> __z <br /> Fi�:csivinrf Foc ay Name: ( J � <br /> 'notal IKG Rl Z; ed: Measonng N1 j6a sect: Container Vairrme'{tf l guired): percentage Fitt(If Required): <br /> Mons <br /> I__.l Pounds <br /> Re stared Trar oNames Vehicle Demi i3um6eG <br /> sR �r _ <br /> x <br /> Bruer Name(Printed): ReoOong Facirdy Rep rdarive Name(Print: <br /> DriverK-C_rrre: J:Zeci 3-Mng FaGil$y Rep —re S'sgttature-. <br /> i <br /> 01 'd 09D 'ON NdHZ � 9106 '6 'q;J <br />