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. 99WON � : �p auai aniaoa <br /> Wd5 Z Cl0 S W 1 P d• <br /> STATE.OF CAL[FORMA <br /> DEPARTMENT SOF FOOD AND AGRICULTURE <br /> Mead poultry and Egg Safety Branch9U _ <br /> 06 <br /> 1220 N Street Manifest'NO:: <br /> Sacra nmto,CA 95$14 <br /> (9167 900-5004 - <br /> - 1 <br /> 79-124 (1-sL 11/12) <br /> Manifest - nedible.Kitchen.Grease''�xanspo a' <br /> )Instructions and Receiving-Faqity Information <br /> A complete - <br /> p hLedib le Kitche>kGrease fIKGTransport MaWest.for a load of IKG consists of this form <br /> ;and all generator copies from-MPES^Form 79-125 (Manifest-Inedible Kitchen Grease Transpo>t ' <br /> :Generator lrofo> atiion�for geii rators'tliiiaf-ddhtit�ute�G to the log&'Aiternativeiy;the-IKG, <br /> transporter may use other forms that contain all required information. All forms in each manifest must <br /> Fhave the same Mani>1`est Numbex-. 'Z'liauspoirtexs mns l;<ee icerup�e+teouanifest i'ox,foco years-' <br /> Winife9t IMstrue-bons: <br /> 1_The driver of the IKG transport vehicle is responsible for entering all information on this form and on MPES Form 79- !� <br /> 125, Manifest-Inedible Irtchen Grease Transport;-Generator•Inform.ation,except.for in thdReceiving Facility <br /> :Representative and Generator RepresenfaUve name and sig 'nature boxes. All entries must be in ink and legible. The <br /> =drnrer must initial.any corrections to information already-entered;i <br /> ,2_ Enter all information in the form below for each load of IKG. Give one copy of the completed form to the receiving <br /> ..1 <br /> faclfty at the time bf 1KG receipt or mail or deliver the'copy to-the receiving facility Within-15•work:,days.' =, <br /> s. <br /> .,3. Enter the Manifest Number found,at the,top cif this form in the Manifest No. box,on the generator form(MPES Form 79- ;! <br /> 125)for each generator that contributes to the,,1oao.'-All 9enerator forms from.generators where IKG was collected to Z I <br /> make up the load must have the same Manifest Number as the attached Receiving Facility Information form- <br /> .4. <br /> orm_'4. Give the generator copy(from MPES Form 79-125)to the generator at the time of IKG collection or mail or deliver the ' <br /> copy_to the generator within 45 calendar days. <br /> 5.Attach the generator forms (MPES Form 79-126)for all generators that contributed to the load of I,KG to this form. <br /> Maintain this form-and-the attach itl generator forms for two years from the date on this form. <br /> AI <br /> Dab of IKG Receipt Time of IKG Receipt Used Cooking Oil <br /> Type of <br /> IKG- InterceptorlTrap Grease <br /> ii <br /> Reconlfng Facility Name_ <br /> Receiving FactrityAddresd ­ <br /> D,T <br /> ""D,'1 C. 0\_ 5 <br /> Total lKG Received- Measuring Method Usad 06ftincr Volume'(If Required): Percentage Fill(If Required): ; <br /> Mons <br /> ❑ Pounds <br /> Registered 7ransporterName- Vehicle Decal Number. ; <br /> X1 5 1r4 C DLDOT e1rL 1� <br /> Driver Name(Printed)-. Recehrii/g FadrV Representative Name(Printed)_ I <br /> Driver Signature: Receiving Facility Representattve,Signature: <br /> 1 <br /> d 165c 'ON WdtiZ l LSH '5 ,A.IW <br />