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sTATF-of CA13fOP.NIA - ,9 9 ti l '°N A S l 6 L l 0 Z S PA a l p a n a a D1a A—RTWONI'OF FOOD AND AGRrC'UL'1TI_RE MSA,Foamy and Egg Safety lurch izzo N SYreez Manifest No.. R fie'-'U5. Sacrmxemm,CA 95914 (916)900-5004 I 79-124 (Esc,1 Utz) _ Mauufest-Iuedt-ble Mtcheu Grease Transport bi ruefio is and ReeTacpW lufOrmation �"I 1 =A complete Tnedffile Mtclten'Vreas a Transport Manffes f dor a load of ISG enn5is-ts of thSs fv m aud aR generator copies fmm IVTPES°Form 79-125(Al2nii£esf-Inedible Mtchen Grease Zrmaspor4 I Generator Y-axoruiatiou7 for geriorators'rat luotftg�Wte 11KG td:the load: Alternatively,-the 1KG , transporter=nT nse other forms that contain aR required mfor=*Aon- AR forms In each manifest must I bane the same I1snil±est Nmxtber: Transporters mist keep completed mfffor.two year Manifest Instructions: 1.The driver of the!KG transport vehicle is responsible for entering all information on this form and on MPES Foran 79- ' ;•125, Manifest-Inedible Kib--hen Grease TFansport Generator Inibi i na6on,'-except for In the Receiving Fadllty l Representative and Generator RepreserrlalWe name and signature boxes_ All entries must be in ink and legible_ The driver must initial any correcfiorrsto infornlabon already entered: 2 Enter all information in the form below for each load of IKG_ Cite one copy of the completed form to the receiving y f 'facifily ai;$I�time of IKG recbipt or mail or deTrver the copy toile receMng facility wilthin'I&work.days. .3. Enter the Manifest Number found atthe.iop i rfthisform 1n the Manifest No.bdx.on the generator form (MPES Form 79- f 125)for each genetatorthat=ntributes to the-load- All genegaW forms•from generators where IKG was collected to make up the load must have the same Manifest Number as the attached Receiving Facility Inform2flon fom-. f 4. Give the generator copy(from MPDS Form 79-125)to the generator atthe time of lKG collection or mail or deliver the copy to the generator within 45 calendar days_ _ I I 5_Attach the gener4orforms(MPES Form 79-125)for all generatars that.rrontributed to the load of IKG to this form_ .Maintain this form and the attached genprator forms foriwo years from the data on this form. Date of IKG ffn, i t Tune of JKG of Cooking Oil 7ypg � W / PM I �nt�roeptorinap Grease i V,�g Facility Name: Recenring Fad'GtyAddre�"""A" - olal IKG P.ecelved. Gallons Measuring Method Used: Corftainervolume'Of RRegerin ' Percentage FSI(if Require: Pounds ZXW lam / p� l2ETed TransporterN3rrl� Vehicle Decal N - } -6rNw Norma(Printed: FU=Wg Fac army Rspmsentat7ve Mme(Pruned-. pr;verSigrraivr� Recd'Mn5 FaaTa)r RepresenfaVva S V. 'd 165L 'ON WdH :z LIE �pW