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LZ66 "N AVSE :9 SI0Z Z 'AON ;W1j pania:;� $TATE of•CAL(FORMA � DEt'ARTMENT OF FOOD AND AGRTCTT�,TTTRI+J � Meat,Poulty and Egg Safety Branch V_� 1MoN street ! ""�-menC00Manifest No:: ��Q 7(S Sacsto,CA 95814 - F � (916)900-5004 79-I24 (Est 111]2) Y Manifest.- >ne , r_v. ..N ^.,�.� 1 dilble-Mfchen.Girease Tir;anspoft Instructions and Recgyv x g ragjity Information �J 'A complete Taedible Kitche>tZ'Grease MKO T1 =Port Manifest.fora load of IIKG consistsof this form all M,... and generator copies from MPES^Form 79-125 Tra ' (Manifest-Inedible Kitchen Grease nsport, Generator Inf6r�aiation)'fhi gexiamtors-tli�f e6rmtrit iQte 1KG to tl e'loif&'Alternatively;the IKG, transporter may use other forms that contain all required information. All forms in each manifest!must � ave the same iVlanifest Nuimber. Transportets`xunsteep:complete manifests fo>c.tivo years Manifest Instructions: c 1. The driver of the IKG transport vehicle is responsible for entering all information on thls form and'on MPES Form 79- 125, Manifest-Inedible Kitchen Grease Transport;;Gpner tor-Information, except.for in the Receiving Facility :Representative and Generator Representative name and*s"g nature boxes. All entries must be in ink and legible. The ll 'driver must.initial.any corrections to 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 receiving facil,y of the time'of 1KG recelpt or mail ordeliver the copy to-the receiving facility within I S,work,.days. 3. Enter the Manifest Number found at the.top,of this form in the ManVest No. box,on the generator form(MPES Form 79- 125)for each generator that contributes ko the•Joad.' All generator forms from generators where IKG was collected to make up the load must have the same Manifest Number as the attached Receiving Facility Information form. 4. Give the generator copy(from MPES Form 79-125)to the generator at the time of IKG collection or mail or deliver the ' copy-to the generator within 45 calendar days_ 5.Attach the generator forms(MPE~S Form 79-125)for all generators that contributed to the load of IKG to this form. Maintain this form and the attached generator forms for two years from the date on this.form. Dats of IRG Receipt Time of IKG Recelptz o Used Cooking 07 J / TYPE i. / Q � 1 PM IKG: erc eptorlrrap Grease Ren�iiing Facility Name: ..J Receiving FacrTityAddresd!' Total 1KG Received: Measuring Metfiod Used: Cbrithinervoiume'MRequired): Fercentage Fill(if Required): ; Gallons Pounds (CCC. Registered Transporter Name: Vehicle Decal Number: a S � r2CzS S r r 124 4 Driver Name(Printed): Receivin 9 Fa©Cdy Rep reser;Wve Name(Printed): Driver Signature: Receiving Facility Represen Signature: c • �l c d�!LzK 'ONf� Wdcs s S�oz z 'AON n '1