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62H '°N &21 :Z LIN 'til '2ny ;W1 j pani ;);� <br /> STATE OF CALIFORNIA <br /> AFpARTMENT OF FOOD ANA AGRYCIJ .TURE <br /> Mead Poultry and)✓gg Safely Branch, <br /> �i 1220 N Street <br /> ! Sacramento,CA 95814 Manifest_ Inedible Kitchen Grease Transport <br /> (916)900-5004 Generator TAforinatlon <br /> 79-125 (Fc.11/12) <br /> Complete forms,starting at bottom. Enter <br /> nerator with n 4 da from <br /> Attaefi'cornPlefed copies o MPES ortri 79-124_�or with <br /> spy attime of grease collection or deliver'to ge Yg' <br /> Time: Manifest.Numle'r_ <br /> i! Date: 7 h PM <br /> 1 Generator Name: <br /> Generator Address' �n rt��. . <br /> UsedCoo i <br /> 1 Maaeuring Method Used: king'O l <br /> Type of <br /> � Total IKG Collected.' Gallons <br /> ! q �1 IKG: Interceptor./Trap Grease <br /> Pounds 1 <br /> Container Gsparab pf Required)=, Percentage F-111(If Required): IKG Authorized Receiving Facility Nam®: <br /> e: rotor <br /> nt i0 4 TO <br /> Transporter Namri <br /> '.fit cf :r <br /> 1 Drtvar Signature' <br /> I <br /> qA <br /> !' Time: � Manrfest'Number. <br /> Date: �I M <br /> Generator Name: <br /> Generator Adclmss: <br /> Mpasuring Method Used: Typaof a Used Cooking Oil <br /> Total IKG Collected: Gallons <br /> IKG: Interceptor/Trap Grease <br /> Pounds <br /> �a <br /> or¢ed Recaivin FaG <br /> C Name. <br /> _ �Y <br /> I Container Capacity(If Required):, PerC2nta a R11(If Required): IKG Auth 9� <br /> 7w 71 <br /> r Rap n ame( rint):- <br /> Transporter Name: <br /> Driver Signature: r R atu <br /> i <br /> :1 <br /> AM Manifest Number. <br /> IDate: Timms PM <br /> j Generator Name: <br /> I' Ge,erator Address; <br /> Measuring Wmhod Used' Used Cooking Oil <br /> Total IKG Collected: Gallons T of ❑ < <br /> I Pounds „ ❑ Intettptbr/TraP Grease <br /> �! Container Capacity(If Required): Percentage Fill(l Required): IKG Authorized Rec6hnng Facility Name: <br /> ii <br /> Al2me nn <br /> Generator Ftepresentative (A * <br /> Transporter Name: <br /> Generator Representative Signature: <br /> w; , + � <br /> E� d" SM 'ON WdH :: LlH til ,,,nV= <br />