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- •�`v N a u til.caVltl�.U�-/�11 K n, 11�ea1;Poultry and E Safety 13z�nch 8 6 l� 'ON AH 8 l 6 8 l 0 Z Z l 'a p N a�UJ i 1 p a A a a a f; . 1220 N Street Man'Ife-st ft.-: Sac=eato,C.P. 95814 (9 1 61 900-5004 I� 79-124 ZL 11/12) Man fest=•lued ble WWhen Gieas `'-Uarisport fustmetabns and Recei -Fac�ifi Informationr •_ - - _- -: ,... f3' A co7tia Iete edx le : , ,. p - Kxtche> Grease iG}TtaWyort Manifest,for a load of TKG• consists of this form ;and all generator copies from:AWES-Form 79-1.25 le Kitchen Grease Transpott emerato><Lafoiiriatnon)for'geliRz•afoxt-t1 co tri?i3-re ISG to ish'dlI kd�-,�4.lternatively;the-MC,_ >fa.'anspox-ter may rise other forms that coutaW all required.imfoxxmtiioxt_ All forms m- ' each rbn.ax[it£est W-Ust ?blamethe saxlxeanid�est Number_ z"ausporters mnseEp=.icolmpleeauests fox-t�vo yeas s 'Man�e�t Instructions= - - - � i f Z d lir 1.The driver of the IKG trransport vehicle is responsible'foreutering all'lnformafion on this form and on 1VIPES Form 79- 125, Manifest-Inedible Kitchen Grease Transpor -Gsnerator-lnformat9en,-except.for In thd.Receiving.Facility Representative and Generator RePresen alive name and sionature boxes- All entries must be in ink and legible. The •'driver must-initialarty evmeciions to information already_entered; i 2_ Enter all information in the form below for each load of IKG. Give one co of the completed form to the receivin PY P Ig .I facility at'ff1e tiit'Ie df IKG recleil3t or mail or•deliverthe copytothe receiving1acpfrty within I5-workdays: _3. Enter the Manifest Number.found.at th�.Yop iof this form in the.Man�Fest Nv. box.on the generator form'(IU�PES Form 79- r, -125)for each generator that contributes to the.,1oad:1All 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. i 4_ Give?the generator copy(from IViPES'Form 79-126)to the generator at the time of IKG collection or mail I�br delivarthe � copy to,the generatorwithin 45 calendar days- 5- a s_ 5_Attach the generator forms (MPES.Fomi 79-125)for all genermors tthat contributed to fhe.load of 1KG to.1-his form- . Maintain this form.-and-the attached deneratorforms for two years from the date on this:form- Dates of IKG Receipt Time of IKG Receipt TyI--1 Used Cooking 07 Typo 1,I Ll i i AM PM IKG: Interceptor rap Gmasa RE c nnng Faciir Name: Receiving lityAddr�''""� - - I - Total IKG .,Raceived_ M—En_ - Tetfibd Usac[: cdgtRinsr Voiume'(IfRequir4d): 'Percentage Fill(If Reequired): Pounds Reg' Transporter Name Vehicle Decal Number 53 Driver Name(PFmt2d)= Reaniving FacMlty ReO Ittahve Name(Pd�lt�:: k i, Dnve� igRatu : YRecOing Rac,Tdy Ra rasentative Slgnaturw L 'd SLH "N NVE : 6 EH Z l 'a pN