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surEOFCALIFOMIA ti909 'ON Ad E ti10 'Sl '�pA aIJJI panla� D►EFilliTX T GF FOOD AND AGIRICULTURE Meat, Poultry and Egg Safety Branch - . .. 1220 NStreet Manifest No.: Sacramento,CA 95814 '- { Rn�� —0,0 �`S (916)900-5004UO PY 79-124 (Est. 11/12) Manifest - Inedible Kitchen Grease 'Transport Instructions and Receiving Facility Information A complete Inedil)le Kitchen Grease(IKG)Transport Manifest for a load of XKG consists of this form and all generator copies from MWES'Form 79-125 (Manifest-Inedible Kitcheu Grease Transport, Generator Tnforu>iatiiou)'for geuerators tbtat contribute IKG to the load. Alternativel the]KG 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. a Manifest Instructions: 1- The driver of the IKG transport vehicle is responsible for entering all information 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 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 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 (MPES Form 79 125)for each generator that con#ributes 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. Date of IKG Receipt: Time of IKG Receipt: �hType of UsedCooking Oil R e c4Mg /Facil` amC.J AM PM IKG' Interceptor/Trap Grease 7 Ree: /,, 7 r (�l I S Receiving Facility Address- to 1 �Ir, 11 Q Tot&1! G Received: Gallons P-) Gallons Method Used: I Container Volume(if Required): Percentage Fill(If Required): El Pounds bL6i"4 ��U � �� • Registered Transporter Name: ` Vehicle Decal Number. 7k2<76 3 Driver Nam®(Printed): ReceivingRepresontat' a Name(Printed): + ��2�-- Driver�qgnature-- Receivin F ility Repres ntative 5i to i 8T/CT 39dd iGiOOa OlOZI 9Z6559b60Z LZ:VT PTOZ/5T/50