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vJ�.�y aye• I <br /> Meg':poultry and Egg Safety Branch 86lE '°N NN8l 6 8l0Z Zl 'a �'N a'�� l paniaaa� 1) <br /> , <br /> 122Q —Street IIIIaI1ITeS$'I`do:: <br /> �acr�tc�to,CA 95814 - � � - � a <br /> --X916)9100-5004 <br /> 79-524. <br /> II1I2) <br /> Mani 4&-st- •Inediible 1�10fien,Grease Tr-" i i! � <br /> Ynstr ettb s a dReeeive _Facility ormai mx>I ai� �1 <br /> . :`A copiplete InedWe Mtehex>i�� �WG Transport Manifesfi,for a load of IKG consists of this for. <br /> �r.- <br /> audalt generator copies fxoloa'MP+,S T'orm 79-125 (Manifest-JaedEble JOtchen Grease Transpoi.-t, 1. <br /> 'Generator foiiriatiori)-f 6-j glezterators-tDKf co-'Sd UZ—We JUKG to$heload.-Mtern.ati 1 <br /> transporter may use other forms that co)3ta£iu,all regt&ed ioaformafion.. All forms inch rifest must <br /> -hzve the same Mau>�est N�ltie J. <br /> f5rajtspoirEers mnsf beep-.compYe$e '�ganzfests fof•two pegs. <br /> Manffest lnstruDbohs: <br /> 1. The driver of the IKG transportwehicle is responsible for entering all information on this farm and on Mp,FS Form 79- <br /> :1 $, Manifest-Inedible-Mchen Grease T ns <br /> jd poi-Generator-Lnforcraaiion,•except.forin the.Receiving FacilrZy <br /> _Representative and Generator Represenirative nafhe and'sidrure boxes. All entries must be in ink and legible_ The <br /> drfiver Frlust;lnitial.any corrections to inforrnaffon already_erftmd: _ li ! <br /> i2. Enter all information in the form below for each load of IKG_ Give one copy of the completed form to thelrecerving <br /> faciTr�yatff�etiiileb�f]CG ��ceiptormailor'deliverthe'copytothereceivingi2cilitywithirr-15workda�ys: I, `' <br /> 'i .. U <br /> S_ Enterthe Manifest Number found,atthe•top,- fthis form 11 in the Manic tNo. bojc on the generatorform(MPES Form 79- <br /> 125, for each eaer-ator that conWbutes to the,{oad_'`All <br /> g _gpnn atorforms from generators where IKG vires collected to <br /> make up the load must have the same ManMast Number as the attached Receiving FacilityInformation form. <br /> i <br /> 4. Give the generator copy(from MPFS'Form 79-125)to the generator at the time of IKG collection or mail for deliver the <br /> copy to the generator within 45 calendar days. <br /> 5.Attach the generator forms (MESS Form 79-125)for all generators that contributed to{he load of IKG to this form. <br /> Maintain this forrwand'tfie attached ger�eratorforms fortwo years from the date on this form. -' <br /> Data of XG Receipt rme of IKG Raceipt rr---�� Used Cooljng Oil <br /> r -typo of <br /> PM IKC Interceptor Trap Grease <br /> Receiving Fwn7r�y Name_ <br /> Receiving Fad'lity Address?'` <br /> Tot2l IKO Recurved_ easi;rmg Miod ilsed CbrifainerVolume If R® ,rad Perren� <br /> Gallons ( � )- t39e1='il!'(IfRequired)_ _i <br /> /J F/ �'� ❑ Pounds Cell !F�9 ✓ �� l> `+' '� _ <br /> Pegistered TriinsporterName <br /> _ Vehicle Decal Number_ <br /> o <br /> 0,NerN jrne(Printed): 9 Y amG PtSnt !° <br /> DmrerSigri�hir�: :' Recd Ing aTrty RepreaantaVve519naturW <br /> I� <br /> i III <br /> S d SLH '°N NH6l : 6 91H 'Z l " pN <br />