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tZ66 "N AVSE :2 S[0z Z 'AIN mull paAl ;�;� STATF,QF CALjFORxm AEPARTMENT'OF FOOD AND AGRICULTUPX Meat,Poultry and E=Safety Branch y 1220 N Street Manifest No.:� ,�/(� /' Sacrl-nento,CA 95814 '`_—U1 q3 �! (916)900-5004 79-124 (Est 11/12) 1VlanfestmedibleiaEclien Grease''I'raia'sport Instructions and Receiving Faq._.Ry �nf LOP .,� - _ _. .., .. ,. ... . is ._ . s.;: - A complete.TaQdzble itche1 i�reasg 1G)'Trar�lsport Manifest.for a load of TKG consists of this form •and all generator copies froom MPES'IForrot 79-125l (Manfifest-Inedible Mtehen Grease Transport, :Generator h&6rlonation)'for genex-ators,tli f—ej5-tHb—ate IKG i'o ihe'lostd:'Alternat"ty,the TKG transporter may use other forms that contai:, all required ionformation_ A.11 forms in each ma west must l have the same Manjfest Number.'T>csnsport:ers innst keeg'completealanfests for.tWo years; J Manifest Instructions: r. 1. The driver of the IKG transport vehicle is responsible for entering all information on this font and on MPES Form 79- 1,25, Manifest- Inedible Kitchen Crease Transport_Generator information, except.for in the Receiving Facility , .Representative and Generator Represenfatve name and'sigrrditure boxes. All entries must be in ink and legible. The :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 fadl y atths tiPile of IKG receipt or mail or deliver the copy to•the receMngfacirtyvftinl5 work.days.' 3. Enter the Manifest Number found at the,top bf this form in the Manifest No_ bax,on the generator form (MPES Form 79- 125)for each generator that contributes Zo the,,load.' All enerator forms from a:+ 9:_ generators where IKG was collected to , make up the load must have the same Manifest Number as the attached Receiving Facil'Ity Infiorma'ton 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_ J 5. Attach the generator forms(MPES 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. `I Data of IKG Receipt Time of IKG Receipt rypo ❑ Used Cooking Oil IKG: (� AM PM r'1 Interceptor/Tran Grease � Receniing Facility Name: v Receiving Facility Address`'"` - Total IKG Received: Measuring Method Us–e.,_ 06nbirw VolumEOf Required): "Percentage Fill(If Required): Gallons i IU 6 q �� j ❑' Pounds I� ��Gi G'I� 72, R89rstered 72nsporrerName: Vehicle Decal Number, a PC Driver Name(Printed)- Reeving Fadrdyresentarive Nam P' RaP e( anted): Driver 5ignature: Raoirving Facility Reprwentatve Signatare: �� 'd cZK 'IN AVLE : S S�H Z 'AIN �