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7 <br /> STATE OF _ - 19WIN 9106 '6 'qaj Mil pan ; ;�;d <br /> DEYWIMENT QF F490D AND AGPJ47M'= <br /> Mead Poultry and Egg Safety Bmnch i � r,�, <br /> la2o N street Manifest No:: '�^ 1"� Ni' <br /> Sacr=ento,CA 95814 <br /> (916)900-5004 <br /> 79-124 Mst l I1I2) <br /> � t <br /> M m fest w Inerlihle 10tchen Grease Transport - �!` � �� <br /> (� a <br /> Instructions and Recei� aefll y Information r <br /> 'A, coMplete IneMle Mtchen%rea'C- ffK,C}Trwnport Manifest fora load of 10KG consWs orris form ' <br /> and all generator copies from;MPES'�Form 79-125 (Manifest-Ined-Lble Mtchen Grease Transport � <br /> Generator Wormation)for generators*at corttt ibWe IKG t6:thw1oad. Aiternstiveiy,the XKG <br /> transporter may use other forms that contatm all required information.. All forms in each manxfrest must I <br /> have the sae 11�sni fest NuTra <br /> mber. anspoi-ters m st k c <br /> m�, ompleted'mariifests_-for•tvvO years. � <br /> Manifest Instructiom: } <br /> 1.The driver of the lKG transport vehicle is responsible for entering all information on this form and on MIKES Form 79- <br /> ij <br /> .125, Manifest-Inedible Kitchen Grease Transport,Generator lnformaficin,'-except for it r the F2eCenring Facility I� <br /> Repr2.5entative and Generator Representafive name and signature boxes. All entries must be in ink and legible_ The 1� <br /> driver must inWai any correclionato information already entgred; <br /> 2. Enter 211 information in the form below for each load of IKG. Give one copy of the completed forint to the receiving � <br /> facility atthe time of lKG rec ipt or mail or definer the copyto-Me receiving facility within 16 workdays. <br /> 3. Enter the ManifiBst Number found at the top bf this form in the Manifest No. bnx,on the generator form(MPES Form 79� ; <br /> 125)for each generator that contributes to the load. Al generator,forms frogenerators where lKG was collected to <br /> make up the load must have the snr nG Manifest Number as the attached <br /> Recerving Facility Information fbm-L <br /> 4.Give the generator copy(from MPES Form 79-125)to the generator at the time of lKG collection or mail or deliver the <br /> copy to the generator within 45 calendar days_ f <br /> 5_Attach the generator forms(MPES Form 79-126)for all generators that contributed to the load of lKG to this form. <br /> Maintain this form and the atWched generator forms for two years from the date on this form, <br /> Date of RCC Receipt rime of[KG Rewipt � Used Cooking all <br /> Type i+ <br /> / AM ]KG. sJrnterwptorfrmp Grease <br /> riving Facirrty Name GLS`- <br /> - <br /> ReCE iWM FaerlityAddr <br /> Total 1KG Received: Measuring Method Used. Cor ainer'voluma'(1f Required): Percentage Flt([f Required}: <br /> GallonsOng- <br /> l-d <br /> El Pounds - <br /> Re&i tared Transporlar Nam= ehide peC3I Number- <br /> Driver <br /> umberDriver Name(Frintad]_ Riving FscH reseratarive Name(Printed)- f <br /> Y-L. <br /> briverS�gnaEur Receiving 07 Raprem tawa. }erre:' 1 <br /> r <br /> lri <br /> f� <br /> L 'd 09D 'ON MN:E 9106 '6 ' 'q;d <br />