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LZ66 "N WbS8 :8 S Z 'noN ;11 1 pan i aoaa 5TAi7,QF CALEFORI,4A DEPAR'PMENT'OF FOOD AND AGRICULTURE Meat,Poultry and Egg Safety Branch 122-0riStreet Manifiest No:: --(J"7G12- Sacramento,CA 95814 - d (916)900-5004 ' '79-124 q-sM 11/12) Man fes = neditXiYe I ache .Qireas4b'T raiiitsport InStxuctiOns and Receiving-Facility Info rmalaion complete Inedible Mt .` P che>� reale(II£G)Ti nsport Manifest.for a load of TKG consists of This form sand sU generator copies frog MPES^korm 79-125 (Manjifest-Inedible JGtchen Grease trans�o- .Generator Tnfoix>ir ai!6n)for gedei-ators'tlx�t co�i&t'b�ute 11KG id the°lo'gd.'Alternatively,.the IKG,• transporter may use other forms that contain, all required information. A11 forms ht each ma�est must � shave the same 1Vlani est Number."TransporteR'xnuii keep::co>rnplaedTmau fesu f6 two years. i Manifest Instructions: f 1. The driver'of the IKG transport vehicle is responsible forentering all'informbbon on this form and on MPES Form 79- :125, Manifest-Inedible Kitchen Grease Transport;,Generator-Information,except.for in the Receiving Facility -'Representative and Generator Representative name and'slgrr3 the boxes. All entries must be in ink and legible. The 'driver must-initial.any corrections to information already°,Angered; i2, Enter all information in the form below for each load of IKG. Give one copy of the completed form to the receiving ii111.1' facilfy at'the time of lKG receipt or mail or'deliver the copy to the rec i-- ing facirtty within•15•work.days. ; 3. Enter the Manifest Number found at the.top�of this form in the Manifest No. box.on tylegenerator form(MPES Form 79- 125)for each generator that cordi*utes to th a.1cad,' 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 gener-tor forms (MPES Form 79-125) for all generators that contributed to the load of IKG to this form_ Maintain this form Wand-the attached generator forms for two years from the date on this form. Rate of jKG Receipt lime 'IKG Receipt Used Cooping OR C -ryps C, ❑" '" �� /l PM 1 IKG: C rtUerceptorffrap Grease Receiinng Facility Na0e: Receiving Faa°rrty Address?- Otal IKG Received: l Measiirin Method Used: Cdritainer Volume If R w r f� Gallons 9 ( e4 °recd: Percentage Fll(tf RequlreG): ` I 3 �� l❑— Pounds �` � � ` � � C) Registered l'ran5porterNamE: Vehicle Decal Number. Driver Name(Printed): Rec2rving FariFdy RepresarraWe Name(Printed): _I Ran �j(I jd�o�CrA Dever Sigpature: ! ReceivrC FaCIRY Representative Signature: f /� ') � \I o1 � ��1 fir` � � !f IV✓ - ;l) �---=� d=LZ9(�8 'oN,� �`P�'/" d WdLB 8 �SIOZ Z noN '�