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o °n auaaniaoa S�A1•k,QF CALIFORNIA 6 8 0 Z ' N W d 8 l �Z L l O l 'til d i 1 P d �11 DEPARTMENT QF FOOD AND AGRICrJLTURE �1 Meat,Poultry and 299-Safety Branch - � 1220 N street Ma n MfeSt I�d:: �(�--�(( f Sacramento,CA 95814 �'��O (91 t7 900-5004 79-124 (Est 11/12) L - 02UI ggi _ . �,I ,, it Mailll f�S7t I>a..edi6 tcI ear .Crease ] r iiu porlt Instructions and ReeeivintgYac ity Information ' L � A complete, ed><'ble I itche re4se VXQ)Tim port Manifest.for a load of IKG consists of this form sand all!generator copies from[MPES Form 79-125 (Manifest-Inedible3itcl;en GreaseTransport; .Generator Inforlooiatioin)'for gezieiratoes f e'oTmt*l bvtL,'jKG ttt the,1'oatid:'Alternatively;tole 1KG transporter may use other forms that contain all required information- All forms in each lmanifest must have the same Mauifest Number. T . - 0'r.- ransporters must]beep:completeid manifest$ wo years-, is f Manifest IMstructiohs: 1. The driver of the IKG transport vehicle is responsible for'entering a l-information on this form and on MPES Form 79- I 125, Manifest.Inedible Kitchen Grease Transport,-Generator Information,except for in thei Receiving Facility ,Representative and Generator Representative naive and sigr*re boxes. All entries must be in ink and legible. The driver must initial,any corrections to information alteady,entared: .2. Enter all information In the form below for each load of IKG. Give one copy of the completed form to the receiving faci '1 rqy at'the bine of IKG rWceipt or mail or deliver the ropy to'the recetvingfacility w1thirr15,work,.days.- 3. Enter the Manifest Number found,at the.topf this fomi in the Mend@st No. box,on the generator form(MPES Form 79- 125.)for each generator that contributes to the,load.''All 9p,nerator forms from generators where IKG was collected to ,I make up the load must have the same Manifest Number as the attached Receiving Facility Information form- 4- Give the generator copy(from MPES Form 79-125)to the generator at the time of IKG collection or mail or deliver the copy_to the generator within 45 calendar days- .. 5_Attach the generator forms (MPES Form 79-125)for all generators that contributed to the load of IKG to this form. s Maintain this form and•the attached generator forms for two years from the date on this,form. Date of Ift keeceipt: Time of IKG Receipt Used Cooking Oil Type of i, / IKG: Interce J �}u AM P ptor/Trap Grease 1� Rec®iVing Faclrity Name: '' qq � ' is Receiving Facility Addre�. " Total IKG Received: Measuring Metliod Used: ICorlrainer Volume'(If Required): Percentage FII(If Required): Gallons i // J a: �� Pounds ��6~ `LaVI , t,.l ; Registered Transporter.Name: VehiGe Decal Number- Driver umberDriver Name(Printed): Receiving Facility Pa resentatxive blame(Printed): Aq Driver Signature: Receiving Facility Representative slgnature: Z 'd SOVON Wd9Z : Z LIH til ',ny :I