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L 9 "N N WdH :9 tiI0 `0 °un0 aWI1 PaAIaDa� TATE OF Cr,.UFORNLk aEPARTMENT 'OF FOOD AND AGRX No.. R R 0 0 88 vleat,Poultry and F-99 Safety Branch � ManifeSt ]220 N Street Coi� Sacramento,CA 95814 (916)900-5004 79-124 (ESL 11/12) Manifest - Inedible Kitchen Grease Tr'an''sport Instrucltions and Recformation U� exvtng Facility In � A,complete Inedible Kitchen Grease 9 ) 'h'ansport Manifest for ale of IKG consists of tbiis .form est_Inedible Kitchen Grease Transport, and all generator copies from MPES Form 79125 CMS Generator Information) for generators that coxitribute IKG to the load. Alternatively,the IKG. Hired information All forms in each manifest must transporter lmay use other forms that contailn all req Manifest Number: Transport Manifest mast keep completedlm►anilfests for two years. i :have the same Manu Manifest ltnstructions: nd onMpES _ Jl j 1.The drivtj er of the IKG transport vehicle is responsible for entering� rtn all pt for thlthe Receiving Facility Form 79 ,125,Manifest-Inedible Kitchen Grease Transport, GeneFa Representative and Generator Representative nadie andeni917 re boxes. All entries must be in ink and legible. e P driver must initial any corrections to information already ve one copy of the completed form to the receiving 2. Enter all information in the form below for each load of IKo the ireceiving facility wfthln 15 work days. . l p ail or deliver thr3 copy facility at the time of IKG receipt or m _ b6x.on the generator form ES Form anifest No 3- Enter the Manifest Number found'at the top'of this form in the r�forms from generators where IKG was(collected to 7 125)for each generator that contributes to the Load. All genera . Facility Information form. make up the load must have the same Manifest Number as the attached Receiving IKG collection or mail'or deliver the 4. Give the generator copy from MPES Form 79-125) to the generator at the copy to the generator within 45 calendar days. load of IKG to this form. at contributed 5. Attach the g eneratdr.-forms (MPES Form 79-125)for all gene a from the ate o }t th Maintain fo this form and the atfiached generatorfiorms for two Yea � r- I t Type of Used cooking 411 Date of IKG Receipt^ Mime of IKG ReceipL, �) M IKG' ItnercePtorri'raP Grease �`I . � AM - � n aclfrtY Name-. R�e� g 1_ o c! - P C � p, iving Facility Address'. L-ad i• S 2 JcontAalner olume(it Required): Percentage M11(if Required); Measuring Memod Used: oizl IKG Received; �� Gallons Pounds Vehicle De11 cal Number. Regr8lered Transporter Name' V_CC IJ Receiving Fa'd ity presentative Name(Printed)'JS Driver Name(Printed)' �Q j � ReceivI Facility signature_ Drnrer Signature: � a f i OT/80 �39"d �Id100d oio�] 9Z6559b60Z 90:-1 bTOZ/01/90