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r _ �_ _ <br /> _._._^—....-----..... o n a u! i ani-a�a <br /> 6802 ' N Wd8l N LION til ' d 1 P N <br /> +; <br /> O <br /> STATE F CALIFORNIA <br /> tIIIIIII�pEpAR'T ___ OF FOOD ANA AGRICU�.T�E <br /> Meat,poultry and E Branch <br /> 1220 N Street <br /> Sacramento,CA 95814. <br /> Manifest - Inedible Kitchen Grease Transport <br /> (916)900-5004 Generator Nformatiion <br /> 01 <br /> 19-125 (Est.11/12) MpES Form 7 124 forthe.load_-Provide generator with coPY <br /> Complete forms,starting at bottom. Enter Manifest Numbers°Attach wrrI CoPies`to MPES`ForTtS y9-124.. <br /> time of grease collection or deliver to g®rrerator within 4- day _ <br /> I1 Manifest,Numb$� r d 4j 1 <br /> i. e:Tim - <br /> I!1 Date: 0 /-7 1 � TE' <br /> IP <br /> Generator Name: 04. <br /> , <br /> Generator Address: <br /> of � Ur;ed Cpoking'Oil , <br /> G; M�asasudng Motltod;Used: <br /> r <br /> Total IKG Collected:' Gallons IKG: Inters eptor/Trap G <br /> 1 �� r-I Pounds <br /> lt�t/ 1._I POn�nt1 a Fill(If RegUlred): IKG Authoried R ivin FadlitY Nam®: <br /> 1 Container CapacitY 011 Reg tired)= �lJ 1 i Q <br /> Generator Rej?resent8tivq�ameM(PA^jn�U� . <br /> �1 orterNsms IG✓�.I 41`t).1JY`" <br /> 7ransp <br /> or t>tative Sign <br /> Driver Signature; <br /> I AM MahiNgt N'timber. <br /> PM <br /> Date_ ; <br /> Generator Name: <br /> Generator Address: <br /> Ge . <br /> Used CooKrng Oil <br /> L Measuring Method Used: of <br /> Total IKG Collected: <br /> Gallons IKG: {nterceptorlfrap Grease <br /> Pounds <br /> wired. 1K0 Authorized Receiving Faplity Name: <br /> 1 Container Capa�4i,Pf Required); Percentage <br /> Generator Representative Name(Print): <br /> Transporter Name: - <br /> Generator Rep <br /> resentative Signature: <br /> Driver Signature: <br /> AM Mand6st Number. <br /> Time: PM <br /> Date: <br /> I <br /> Generator Name: <br /> ! Generator Address: <br /> Wood Used: p Used Cooking Oil <br /> Meth <br /> E Measuring Type of <br /> Total IKG Collected: p Gallons IKG: r I 1nterceptor/Trap Grease <br /> LJ <br /> ...Pounds <br /> ! - Container Capacity(If Requlred): <br /> Percentage Fill(If Required): IKG Authorized ReceN'n9 Facility Name: <br /> Generator Rep reserdatitre Name EPrint): <br /> i Transporter Name: <br /> i <br /> Generator ReOreseflIMMI Signeturp. <br /> WdLZ : Z LION til any <br />