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s4.,TE9'FCALIFORNIA ti909 '°N WdEZ :E ti[OZ 'S [ 'A�N auiil paAI ;D;d AEPNRTMENT OF FOOD AND AGRICULTURE Meat,Poultry and Egg Safety Branch 1220 N Street t Manifest No.: 122 - 0013 ` Sacramento, CA 95314 (916)900-5004 79-I24 (Est. 11/12) a Manifest - Inedible Kitchen Grease Transport Instructions and Receiving Facility Information A complete Xnedible Kitchen Grease (IKG) Transport Manifest for a load of IKG consists of this form and all generator copies from MPEsTorm 79425 (Manifest-Inedible Kitchen Grease Transport, . Generator Information)for Igeneratolrs that contribute IKG to the load. Alternatively,the IKG transporter may use other forms that contain all required information. All forms W each manifest must have the same Manifest Number. Transporters must keep completed manifests for two years. Manifest Instructions: 1. The driver of the!KG 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 contributes to the toad. 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: Used Cooking Oil Type of 0 IKG:� PM � Interceptor/Trap Grease Receiving Facility ame: , Receiving Facility Address: I Total IKG Received: Measuring Me od Used: Container Volume(If Required): Percentage Fill(If Required): Gallons Poundslr U� Registered Transporter Name: Vehicle Decal Number, Driver Name(Printed): Receiving Facility Representative Name(Printed): tiAore, z V\ L� I\ Driver Signature: ReCeivi g Facility Reyntativ S.gnature: 8T/60 39Vd �J=Od 010ii 9Z65S9b6aZ LZ bT bTH/5T/5e