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L1E9N WdZ0 9 til0Z '0 r aril paAia�a� STATE OF CALIFORNIA DEPARTMENT OF FOOD AND AGRICULTURE Meat Poultry and Egg Safety Branch Manifest No.: 1220 N Street Sacramento,CA 95814 C OXI%h (916)900-5004 { 79-124 (�11112) j Manifest -�fne&6Xel<itcUiu7arease Transport � ! Receiving � Infon Facility rmlation Instructions and R A complete Inedible Kitchen Grease Opi G)Transport,Manifest for a load of IKG consists of this form,. and all generator copies from MPES°Forte 79-125 (Manifest-Inedible Kitchen Grease Transport, .. Generator Information)for generators that contribute IKG to the load. Alternatively,the IKG transporter may use other forms that contain all required information- All forms in each manifest must , have the same Manifest Number. 'Transporters must keep completed manifests for two years. Manifest Instructions.: 1. The driver of the IKG transport vehicle is responsible for entering all information on this form and on MPES Form 79- l 125, Manifest- Inedible Krtchen Grease Transport, Generator Information, except for in the Receiving Facility Representative and Generator Representative name anq signature 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 facillty at the time of IKG receipt or mail or deliver the copy to the receiving faclfrty within15 work days. .3. Enter the Manifest Number found at the top of this form in the Manifest No. box on the generator form (MPES Form 79- 125)for each generator that contributes to the-load. 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(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. Dateof IKG Receipt: Time of IKG Receipt TYPo of Used Cooking Oil AM PM IKG: Interceptor/Trap Grease Receiving Facility Name: L 10 Receiving Facility Address: 1 �hEA � Total IKG Received' Measuring Method Used: Containervolume(if Required): Perceitge Fill(1f Required): Gallons � Pounds Registered Transporter Name: C�.T vehicle Decal umber Driver er Narne(Printed Receiving Facility Represen%tive Name(Printed): �3at�ce M aC C%-Vl�b Driver Signature: R ivi g Facil'rry Representative Signature: �. I I, OT/Z0 a]LODN 0101 9Z6559VGK 90 :LT bT0Z/@T/90