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1_ o 0 d auaiaaa <br /> --- 6802 ' N Wd8l Z til An i l P n , <br /> STATE OF CALIFORNIA <br /> nEPAR't'M�NT OF FOOD ANA AGgICYJ�.TURE ., <br /> Meat,Poultry and Egg Saf ty Branch, <br /> 1220 N Street <br /> Sacramento,CA 9581a Manifest- Inedible <br /> Grease "Transport <br /> (916)900-5004 Generator Information <br /> 79-125 (5st.11/12) <br /> Complete forms,starting at bottom- Enter Manifest Num MPES Form 79124 four le <br /> MpES F79-124-.rater with copy at <br /> time of grease collection or deliver'to generator within 45 days' 'AtpclalcomPlefed cop <br /> Marircest Numb®r0(1 <br /> i Date: Time I, -', �i_, <br /> 1 <br /> Generator Name: <br /> GeneratorAddre55 1 I �1_. Q . . <br /> Measuring McNod.,Uzed:'. <br /> Type of 'Weed Cooking Ol <br /> f <br /> Total IKG Collected: Gallons'.: � IKG: interceptor/Crap Grease., :, <br /> , ^� <br /> l�-� Percentage Fi11(If Rgqu{red): IKG Aut <br /> Chorized ReceivinFaclf Name: <br /> ontainer Capaca y(1f Required)' G <br /> Generator Repne 'live Name(Print)_ <br /> Transporter Name: —'� <br /> live i n re_ <br /> Generator Reg <br /> Driver 5�gnature: •• <br /> AM <br /> i Maiti'rfe�t Nlim r. <br /> Time: PM n r+ <br /> Date: " <br /> Generator Name: " <br /> Generator Address: <br /> 1�I Measuring Method Used: Type, ❑ Used Cooking Oil <br /> Total IKG Collected: l..-1 Gallons: . n <br /> IKG: L:J Interceptor/Tmp Grease <br /> Pounds L:J <br /> 1 Container Ca,paclp�(If Required): Percentage Fill(If Requi": IKG Allthor¢ed R®ceMng Facility Name: <br /> i <br /> Generator FdePnr�Name(Print): <br /> Transporter Name: <br /> Generator Representative Signature= <br /> Drtver Signature: <br /> j TimeM Manifest Number. <br /> Date: <br /> - n <br /> Generator Name: <br /> i <br /> Generator Address: <br /> Measuring Method Used: Type of - a Used Cooking Oil <br /> Total IKG Collected: Gallons <br /> � KG: F] Intert:eptodTraPGiease <br /> ...Pounds <br /> Container Capacity(If Required): Percentage Fill Of Required): IKG Authorized Receiving Facility Name: <br /> Generator Representative Name(Print): <br /> Transporter Name: <br /> �IDAver Signature: Generator R6dresentdtive Signature: <br /> I' 01 'd_..ss 'oN N ' " WdLZ Z rLIOZ til 'any <br />