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ti909 '°N WdH E tiI0 'Sl 'APN auiil p;Ai SM4TE 9F dALIFORMA TIv NT OF FOOD AGRICULTURE Meat,Poultry.and Egg Safety Branch 1220IN Street :. . Manifest No.: oco 8 Sacramento,CA 95814 � ,;r ". (9]6)900-5004 79-124 (lst. 11/12) `�/ Manifest - Inedible Kitchen Grease Transport Instructions.and Y2eceiving,Faci.iiity Information A.colmplete Inedible Kitchteia Grease(IKG) Transport Malalifest,for a load of IKG consists of this form and all generator copies from MFES'F'.orm 79-125 (Manifest-inedible Kitchen Grease Transport, Generator Information)for generators that contribute II£G to the load. Alternatively,the IKG transpolr,.ter may use.•other forms that contain all required information. All forms in each manifest must have the same'Mgnilfest Number. Transporters must beep completed manifests for two years. Maniifest Instructions:... 1'.The;driver of the IKG transport vehicle is responsible for entering all information on this.form and on MPES Form 79- 125, AAanifest- Inedible Kitchen Gi ease•Transport, Generator Information, except for in the Receiving Facility Representative and Generator Representative name apd,signature boxes. All entries must be in ink and legible. The driver must initial any corrections to infoiffiation,already'eintered. - 2. Enter all information in the form below for each ioad of IKG. Give one copy of the_completed form to the receiving facility at the time of IKG receipt or mal'or deliver the copy to the ieoeiving 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 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 contdbpted to the load of IKG to this form. Maintriin this form atld the attached generator forms for two years from the date on this form. Date of IKGcelpt: Time of IKG Receipt Type Used Cooking OII /��y . p PM IKG: interceptor/Trap Grease GD Receiving Facility Name: i"i-P- � r,s G 1..1. Receiving FacilrtyAddress: 39 4-o In R& d' Total IKG.Received: Measuring Met d Used: Container Volume(if Required): Percentage Fill(If Required): 'Gallons Pounds Registered Transporter Name: b Vehicle Qecal Number iy 777 �� '125 � �- �C�o��Q✓ Driver Name(Printed): Race -ng Fadi Y.Representaove.Name(Printed): Driver Signature: Recefvin acilfty Representative Lure: 8T/90 119Cd d3io0a 0101 9Z6999b60Z LZ:bT bTOZ/9T/90