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--.... . ... ... _ .. ... _ -HE 'IN Wd9I Z L til 'any awiI p;A I ;d <br /> I; STATE DOFF Cr�AUFFOOR�N�+IrA� y� �7� n7 <br /> DEPART l�'a-�-�l�� OF FOOD AND AGRI� <br /> Meat Poultry and Egg Safety Branch, <br /> 1 � X220 PI Stzeet <br /> Sacrameacv, c,�r 9r�f� jV�arl�fes[- Imedibic Kitchen G•resse Transport <br /> (916)900-5004 Generatorformation <br /> 79-125 (Est,11/tZ) <br /> Complete forms,starting at bottom. Enter Mantfest Numijer from PES Form 79-124 for the loadProvide generator with copy at <br /> time of grease Collection or dellver'to generator within 45 deys3.Attactl)complef9d cwiesto MPBE--Fonni 79-124.. <br /> it , . I•. n: t. <br /> Date: �/ ✓�l Time: JV� RM <br /> IManifest.Nurnti�r. <br /> I , <br /> : k <br /> Generator Name: 1 `Y <br /> 1✓l�t 4 <br /> Generator Address: <br /> ` Mdasuring Msthod;Used_. ,-' 'Used Cpoldng'Dil <br /> Total IKG Collected <br /> Gallons - Type ofIda <br /> ❑ <br /> 1 r1 n e1 Pounds Cy, �I IKG: Interceptorf crap Grease <br /> Container Capacity(If Required): Penentage FA(if aequired): IKG Authorized ReoWng Fac Name: <br /> Transporter Name: Ge_ner8tor ReQre9entatide Nares(Print):. f <br /> DAVer Signature: Generator Representative Signature. <br /> I ➢ AM Number. <br /> Date: lime: PM MaNest . ,r b <br /> �• <br /> Ganerator Name: <br /> Generator Address: <br /> Total IKG Collected: Measuring Method Used: of Used Cooking Oil <br /> Gallons 1 <br /> U� Pounds r lKQ' Interceptor/Trap Grease <br /> ❑ <br /> i Container Capsrty(If IiequFred): Percentage Fill(K Required): 1(�G A or¢ed Receiving Facility Name: <br /> �. •� <br /> Transporter Name_ Generator Representative Na a(Pri <br /> priver Signature: r Representative Signature: <br /> i Date: nme.- I PM Manifest Number_ <br /> T <br /> o /I <br /> Generator Name: <br /> I Generator Address- C <br /> I' Measuring Method U _ Used Cooking Oil <br /> Total(KG Collected: Gallons Type of ❑ <br /> Pounds Il<G. InteraeptorrFrap Grease mer <br /> Container Capacity Of Required) Penxntage Fill(if Required): IIKG Authorized Recetving Facility Name: ❑ Name 0 <br /> Transporter Name: Cenerater Reprepmh ve Name(Pdnt): erg/gra ,� <br /> 6. <br /> ` Driver Signature: Generator RepresentatNe Signature: <br /> Wd :Z 'L [H 'tip '2nd <br />