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Mlfea4 Poultry and Egg Safety Brmch 8 6 1 EN W a 8 6 8 l 0Z 11 P a n a a <br /> )z0N sUL-at man'rtest No:: <br /> Sacr?, 2nto,CA 95814 <br /> (916):900-5004 `. <br /> 79-124 (,Est 11/12) I i� <br /> Manifest-Xnet ble J�Ifchen.Grease''I'rausPort <br /> Yustrucf3 s a>ad ReeeXVW2 acx t� ormation <br /> -� - _ <br /> A complete �Le I tcli 1 , ' ) raasp <br /> Ti�edi eln Greage If , ort Ma�ai�est.for a l ad of JJKG consists of this form <br /> -.and A generate-copies fr•om-MFES'Form 79-M(Manifest-Ynedible Kitchen Grease Tra4spof , <br /> it <br /> :Generator Itifo»atiolol)fbir generatops-tT>i co t7t'lliQte' G do&e'lo 'Aiternatively;the-Int t, <br /> "'asporter may rise other forms that co))taW all xequked Wfoxma#ou_ AM foxxns in each.xeau£ifest Faust <br /> !lave the sa-mi"e Wiest IV' b <br /> � e�-�5ransporte><s trnt�.sf deep-:colEaplefec .-manifests fm�.tovo yeses. <br /> Manifest Instrueflons: c' <br /> 1.The driver of the IKG transport vehicle is responsib[9'for entering all information on this form and on Min' 'S Form 79- <br /> _126, K41anifest-Inedible-Kitchen Grease Transport,-Generator-lnfotmaliQn,except for in the.Receiving Facility <br /> ,'Representative and Generator RepresenLabve narhe and'sidri,Lure boxes. All entries must be in ink and legible. The <br /> -driver must Wtial.any corrections to information alteady_entbred <br /> �j <br /> e.2_ Enter all information in the form below for each load of IKG. Give one copy of the completed form to thel receiving <br /> facifty aftheitit'1e bTiKG r6obiptorWeil or"deliverthe'copyto-the receiving-Pacirrtywithin 15-workdays.- <br /> ;3' Enter the ManifestNumberfoundatthe.topAfthisform in the Manifest No. box on the generator form(MPES Form 79- <br /> 125)for each generator that contjbutes�o the,1oad''All generator forms from generators where IKO was cofiected to <br /> make up the load must have the same Manifest Number as tete attached Receiving Facility Information form_ ' <br /> 4_ Give the gene>ator copy(from NiPES'Form 7125)to the generator at the time of iKG collection or mail fbr deliver the <br /> oopy-to the generator within 45 calendar days, <br /> 5.Attach the generator forms (MPES Form 79-125)for all generators that contributed to the load of IKG to this form_ <br /> Maintain this forr and the attached generator forms for two years from the date on this,form. <br /> pate of IKG Receipt= Time of IKG Receipt <br /> Type of EJ Used cooking Oil <br /> \ , AM PM IKG= n erceptorTrap Grease <br /> Recsrving FacifdV Nsme <br /> Recaiving Farr rty Addn <br /> Total 1KG Recalvod,_ Measuring MetFod Used: ConlainerVolume(If Required): "Percentage Flli(If Required); <br /> Gans <br /> 0' Pounllods ` � 1 <br /> Regisr(ered Tran orterName: <br /> � Vehicle Decal Number: e � <br /> Dm/or Name(Printed): ReceivinG+121Y1E(Pd rted); <br /> Driver5ignaturW_ Faali�/RaprBsen five Signature: <br /> lam+ --- -1 <br /> 'd SL86 'ON INVE : 6 ER z l " �W <br />