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(6Z0 'ON AVE :: ( 9 (H 'E 'A ON awil 'PaAI ;3ad <br /> STATE OF CAL1F0RI lLk - !� <br /> I E PARTAIENT 0,F Fo-oD A"AGPJCUL TD_R_ E h <br /> Meat,ponitry and Egg Safety Branch ) <br /> 1220Nstreet - Manifest No:: (� <br /> 6acxamento,CA 95914 <br /> (916)900-5004 ` <br /> 79-12.4 CV-r-I1/1M) <br /> Tuedible Kitchen Grease Mr ?ort <br /> %actions and Rece]�v -F,aeMty Info n <br /> .A complete inedible Kitcher ease. Transport Man;ffest for a load of EKG consists of AU form <br /> ._,and aJU generator copies from A PESTorm 79-725(M2nffest-Tneffible,K tchen Grease Transport, <br /> Generator Wormation)-for generators t5.at k6ntfibftte ISG to'thelon& Alternatatveip,.Ihe IKG _ <br /> transporter way use other forms that coniabj an reqs ed mforhuMon- All forms nj each manifest mast � 1 <br /> IuLve,the same lAmaest Nn6 bar_ Tx�asportets 70gnst beep Cozrotpieted mami�est5 or.tWo year <br /> Manifest Instmebons: <br /> 1.The driver of the IKG transport vehicle is responsible for entering all-information on this form and on MPES Form 79- <br /> -125, Manifest-lnedVL--Kitehen Grease Transport, Generator lnfUm a8on,'zxa3ptTor in the Paving Faclmy <br /> Representative and Generator RepresentaEve name and sigfzature boxes_ All entries must be in ink and leglble_ The <br /> driver must inrb-al any corrgctions.to Mfamaagon already entered; <br /> 2 Enter all information in the form below for each load of IKG_ Give one copy of the completed form to the receiving <br /> {acTrty at the time of lKG rec ipt or marl or definer the copy to-the receiving facTrEy wlthin-f 5 workdays_ <br /> 3. Enter the Manifest:Number found atthe tap bf this form in the Manifest No_boxon the generator form (MP ES Form 79--• <br /> 92a�for each generator43121t cQnfr4butes to the load- All gTner_rforrns_from generators where lKG was collected ts� t <br /> make up the load must have the same Mantfest Number as the at�ched Receiving FaoTrty Information form <br /> generator of the time of iKG collection or mail or deliver the <br /> •4_ Give the generator copy(from MPES Form 79-125)to the genr <br /> I <br /> copy to the generaiorwrthin 45 calendar days. _ <br /> 5-Attach the genera or forms(MPES Form 79-125)for all generabxs that conte-bufed to the load of IKG to this form_ <br /> Maintaln this form and the attached generatorforms for two years from ifie date on this form. <br /> Dam of H<G Peceipt cane of IKG RncalpL <br /> Typo of Used Coo1� g OU <br /> Q �. <br /> _1 0 ! � PM IKG fineroeptorlrrap Grease <br /> Rao rvurg FaaTdy Name: `7 �"� <br /> Re�iv&7g Pac�ityAddr��Y � � 6 <br /> Total IKG Received: Meag N1elriod Used: coTrwinervol une•pf Rees <br /> Requires_ Percentage Fal(If Reqused)' <br /> r3a[lons <br /> LI Pounds I bi t/� 6q <br /> Reais�r2tl Transporter Name Vehicle Decat Number - <br /> � �n - o <br /> Driver Names(Pruned): Receaviri9 F=ac>rrty 'B Namur(Pra*>�= <br /> iA&LU, & <br /> Driver S(gnah>r� -- f7 rig F�a�y F�ePrsser�ative S+ - f1 <br /> r <br /> t� <br /> 6 'd 99E9 'ON AVtiZ : 0 l 9 (0Z 'E 'AGN <br />