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1620 '°N AV91 :01 91H 'E 'AON ;wI j Pani ;); S A CF-OF CP--FORIq[A M DEPAR'FNIII�T'r�F FOOD AND AGRJCUL'TTTX Meal,Poultry and Safety$r�ch _ Manifest No:: 122.0 N Suset - Saccamento,CA 9581.4 - (916)900-5004 ` 79-L24 (EQ 11/12) Afanifest- meth~&schen Girease Transport - L T / . ' T ' I formadon hlstruct�lbnsd Recew�uxg cality P II 'A compiete Taedble Krtchepe 9EQ Triwporti JVIan est for a load of MG consists of this form stud an generator copies from NTFS, rm179-125 (Mangiest-Inedible schen Grease Trauspo Generator Information)-for generators that contr:Zffle IKG tdAhe•load_ Alter�ative3p,the 77 G . ' transporter may use other formes that contain aH required idorma on. Ail,forms in each manifest must -Dave the same 11'Iaani#•est Number: T ansporters'must deep for-two years. JIManifest Instructions: 1.The driver of the IKG transport vehicle is responsible for entering all information on this form and on MPES Form 79- :125, Manrrgst-InedNe Ktteherr Grease Transport, Generator lnfbn retion,'.exmpt for in the Riving Facility Representative and Generator Representative name and sigftature boxes_ All entries must be in ink and legible- -the drt ver must initial any correddonato information already entered; 2. Enter all information in the form below for each load of IKG- Give one copy of the completed form to the recelMng ,I faci ay at1he time of lKG receipt or marl or deliyer the copy to-tha recerving faculty wrthin I a work.days. 1 3. Enter the Man fest Number found at the top bfthis form in the Manifest No. box.on the generator form (MPES Form 79- 125)for each generator that contributes to the load_ All generatorforms•from generators where IKG was collected to 4 make up the load must have the same Manifest Number as the 2dtached Reserving Facility Information form- from MPES Form 79-125)to the generator at the time of IKG collecfion or mail or deliver the l 4_ Give the generator copy( � copy to the generator within 45 calendar days. 5_Afiach the genen&r forms (MPES Form 79-12 for all generators that,contributed to the load of IKG to this form. Maintain this form and the ached generator forms for two years from the date on this form, attached DatQ of IKG Receipt -rare of IKG Receipt Ej Used coordng oa TOfype moi /!, �o I ' PM InterceptorlTrap G ease i v Faoi N R cEive: Recehang F=HifyAddrass—�'— G C� �5 Tata)IKG F2eC2ived Measuang Method Used: Oon'tainer Volume Of Raqui�= Percentage Fill Of Raquhz4: I-"I Pounds //,z)m Reg>stered TraospOrtar Name Vehicle Decal Number. Driver Name(PrintaCU: R�nnng FacW Rap Name(Prurted): 7it G � briverSignahrr RecdM FaaTrfty Representative Signshrre:' _ _ I JX I; 9 'd 9H9 'ON AVtZ : 01 9tH 'A ON