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l9ll 'IN AV�Z :OI LIOZ 'S 'add 2W11 pania)ad S'i;A'CEOF CALIFORrILa DEP"TWENT OF FOOD AND AGRICULTURE Meal;Po trftt and Egg Safety Erauah 1220 N Street Manifest Nd. �- �C�5 . Sacramento,CA 95814 (916)goo-soca 79-124 (Est II/I2) � Manifest- Inedi-ble Kitchen Grease Traias ort Instraetions and ReceiviugYac4ity Information 'A complete InedWe Mtch"rease 9Y,.G.)Transport M= f'es-t for a load of IKG cola bt's of*U form. ..anal all generator copies from MPES Torm 79-125 (Manifest-Inedible 16tchen Grease Transport, Generator Information)-for generators that cdnt6bate]KG t6'the•load. Alternatively,the Yf£G , transporter may use other forms that contain aU,required Information. AA forms in each manifest must i 'have the same 11�est Number. 17ansportets'must keep comp16ted.-lollam%festR for-two years. Manifest Instructions: 1.The driver of the IKG transport vehicle is responsible fur entering all information on this form and on MPES Form 79- A 25, Manifest-Inedible Klfehen Grease Transport, Generator lnfortuaiion,',==pt for in the ReceMng Facility Representative and Generator Representative name and signature boxes_ All entries must be in ink and legible_ The driver must initial any cor-ections.to information already entered-. F� 2. Enter all information in the fonn below for each load of IKG. Give one copy of the completed form to the receiving faciflty at he time of IKG receipt or mail or deliver the copy tolhe receiving facility within-t5-workdays. I 3. Enter the Manifest Number found at the top bf this form in the Manifest No. box.on the generator form(MPES Form 79- •125)for each generator that contributes to the load. All generator,forms from generators where IKG was collected to make up the load must have the same Manifest Number as the attached Receiving Facility Information form-- 4. 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 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 I KG to this form_ Maintain this form and the attached deneratorfnrms for two years from the date on this form. 1 Dsb�of KG Recelpt Time of.IKG ReceiptType of Used Cooking Oil ❑ / IKG: laterceptorlTrap Grease Receiving FaciW Name! F w L Flo 3 Rsceiving FacTity Addt�'-- 2 rte" ra Yi 11 a GQ oc1.L 2-- Total IKGReceived- Measuring Meewd Used: Container Volume'Of Required): FerwnF tage al(if Reuva qct): F1 Gallons :;'0 ns�,1 0 Pounds � � C Regi;t r T rter Name- ( Vehicle D Number. Driver Name Pring: Rec6iving Faday Rjapfe5eXtabve Name(Trow: I Drnier Signature "ing Facile Representative sigmtu i rI • F 6 d LEL 'IN NVE : Ol LlH 'S 'add