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16N 'IN ME :01 91H 'AON ;WI J `paAl ;);� <br /> SAIF <br /> OF CA1.1FORrIIA <br /> DEPARTMENT OF F'O'OD AND AGRxC MTUR_ E i <br /> Mem Ponivy and Safety'Brach _ Manifest No::122--03 <br /> 1.220 N Street <br /> Sacramento,CA 95814 i <br /> (916)900-5004 <br /> 79-LZ4 (Mc 1 ina) <br /> Max>vifest - Inedible Mtchen Grease Transport - �- o2-1 <br /> XiaitrluucLalbns and Recewing TacffltY Imformation <br /> 'A complete Ined%le I�rtchen`Grease�IgtG�Transport Manifest for a load of IRG con�Ws of this form <br /> ..and an generator copies from MPESTorm 79-725(n?an>�esi -Inedible Kitchen Grease�5ram sport, <br /> Generator I-aformation.)"for generators•that zoir'.iribme XKG t6the load_ Alterna#i W,_the IXG 1 <br /> transporter may use other for7tns that contaSn an required Smfor"gon. Allforms in each manifest mast <br /> `have the same Ma7ni est Number- Transporter s.must keep cQmpleted-itina>nffests fof-two pears_ i <br /> Manifest Instructions_ <br /> 1.The driver of the IKG transport vehicle is responsible for entering all information on this form and on MPFS Form 79- <br /> :125, Manrfezt, Inedible IGtchen Grease Transport Generator Infnrmafian,'exceptfor u7 the Receivrng F2ciGty i <br /> Repnesent-a(ive and Generator Representative name and signature boxes. All entries must be in ink and legible. The <br /> driver must initial arty corections.to information already entered; <br /> 2- Enter all vformafion in the form below for each load of IKG. Give one copy of the completed form to the receiving _ <br /> fac rTty at the time of IioG re ipl or mail or dealer the copy to receivitmg facil"lty wfthin-15r work.days_ <br /> 3_ Enter the Manifest Number found at the top Df this form in the Manifest No_ box-on the generator form(MPF-5 Form 79- <br /> 125)for each generator tlratcnntnffiutes to theaoad. All generatorforms,from generators where IKG was collected to <br /> make up the load must have the same Manifest Number as the attached ReeeMng Facility Information form. <br /> 4. Give the generator copy(from MP ES Form 79-125)to the generator at the time of IKG collection or mail or deliver the <br /> copy to the generatorwifhin 45 calendar days_ _ <br /> I <br /> 5.Attach the generator forms(MPES Form 79-12 for all generators timet contributed to the load of IKG to this form. <br /> Maintain this form and the attached generator forms for two years from the date on this form. l <br /> 1 <br /> • I <br /> of IKG Receipt TrMe of IKG Reogipt Type T of T- I Used CookMg Oil <br /> � L--1 !- <br /> �/y� rrtEr�ptor/Trap Gfeasot <br /> /4� AM <br /> RP.pM_n Faa, Name: <br /> Rec a:W- g Facility Adams. <br /> Measuring Method Used: CortTaine7?olume'(IfRequiired). Percentage Fal(if RegviriAl - <br /> Total IKG <br /> - El Pounds <br /> F2egisLerrd Transporter Name Vehrc(el D�ecar Number - <br /> Sresent�ve Name(Pi$� -. <br /> Driver Name(Printed)' Recer,ing Facr7Fty Rep 'I <br /> 0�2V DU Receiving FaaTV[ pr rttabtie ftnetum, {! <br /> Driver S` rec 4 <br /> ).i <br /> 'd 9H9 'ON AVH :0I 9lH AON <br />