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s7 SOF CALIFORNIA ti 9 0 9 '°N M E ti l O l S l 'A P W a w l p;A i rA�2TIVIEENT OF FOOD AND AGRICULTURE Meat, Poultry and Egg safety s»on Manifest No.: r -eo2c.� 1220 N Street 1 Sacramento,CA 95814 (916)900-500.4 79-124 (Est. 11/12) Manifest - Inedible Kitchen Grease Transport Instructions and Receiving Facility Inlformation A complete Inedible Kitchen Grease(EKG)Transport Manifest for a load of IKG consists of this form and all generator copies from MPESFokm 79-125 (Manifest.-Inedible Kitchen Grease Transport, . Generator Information)for generators that contribute IKG to the load.�Altelrlaaiively,the i KG transporter may use other forms that contain all lreiluired-iurformation. All,forms in each mamifest must g have the same Manifest Number. Transporters must keep completed manifests for two years. Manifest Instructions: j 1. The ddver'of the IKG transport vehicle is responsible for entering all information on this form and on MPFS Form 79- 125, Manifest-Inedible Kitchen Grease Transport, Generator Information, except for in the Receiving Facility Representative and Generator Representative name and 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 ==.1 facility at the time of IKG receipt or mail or deliver the copy to the receiving facility within 15 work days. 3. Enter the Manifest Number found at the top of this form in the Manifest No. box on the generator form (MPFS Form 79- f 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 MPFS 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_ 1 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 end the attached generator forms for two years from the date on this form. Date of IKG Receipt: Time of IKG Receipt: Type of ,�Jn�rcaptorlrrap d Cooking Oil j 1KG: Grease Receiving Facility Name: Receiving Facility Address' Total IKG Received: Measuring ethod Used: Container Volume(If Required): Percentage Fill(If Required): Gallons 313 . 9 >� Pounds Registered Transporter Name: Vehicle Decal Number. rz 7 - Driver Name(Printed): ReceMng Facility Representative Name(Printed): NA 0,C-0M 1� 4rlver S' nature: Re vin Facility Representative Signature: IZ 8T/5T :19dd d3ioo�1 0101 9Z6559b60Z LZ:bT bTez/5T/5e