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l9ll ',N AV�6 :0I LIOZ 'S 'add ;WIJ pania3a� <br /> STA"j,E OF C4r..IFOR2 u& I� <br /> 17 A 2 <br /> OFFOOD AND AGMCMLT= li <br /> MeaR R�Og5C L <br /> Meat.Po and _- <br /> 1220 N Street sai�ty stanch �- Manli=est No:: <br /> Sa rrame=o CA 95914 _ <br /> (916)900-5004 <br /> 79-124 (FIL I V12) <br /> Ma3affeSt-Ynedi"ble Mtehen Gr reaso Transport <br /> Insti ctom and Ree ezvi�t Tacility Information <br /> `�� � <br /> 3A complete InedWe Kitchea-Wrease gMG)1r=sport Manffest for a load of IgG congists of this form <br /> and aIl generator copies from MPES Form 79-125(Manffest-Inedible M"en Grease Tramvor>L, <br /> Generator Tmfomiatiioln)for generators`mat Edntznbidte ISG to:lhe load. AlternattCely,the IKG • <br /> tranapoxter may lase other foram tha±contsiu a'd areganred 3tafoxirnat OXL- A31 fox-xn iia ea.clx mammest must ! <br /> -have the same MuAfestNnmber. TI .a porters'mnstkeep completed- ests-fox-two years. <br /> itManifest Instructions: <br /> 1.The driver of the IKG transport vehicle is responsible for entering all information on this form and on W S Form 79- it <br /> 125, Manifest-Inedible Kitchen Grease TFanspvrt Generator Infam-anon;.except for in the ReceMng FaciGiy i I <br /> RepresentaUva and Generator RepresenlalIve name and sighatvre boxes_ All entries must be in ink and legible. The !� <br /> driver rnust initial any coneaflonato lnformafaoo already entered: <br /> _ f <br /> 2 Enter all inlbrmaHon in the form below for each load of lKG_ Give one cppy of the completed form to the receMng. <br /> fact eLy atibie time of lKG reo2ipt or mall or delttverthe copy to-the receiving faciritywWri-15work_days= <br /> t <br /> _3_Enter-_ Manliest Number found Sithe bop bfthis form in the Manifest No_box on the genera#orforni(MPES Form 73- f <br /> 125)for-ach generaiorthat contributes to th.e load_ All.genm7tctrforms-f m generators where IKG was collected to <br /> make up die load must have the same Manifest Number as the attached Receiving Facility Infbanation fon-n. 4 <br /> L4. Give the generator copy(from MPES Form 79426)to the generator atthe time of lKG collection or mail or deriver the <br /> copyto the generatoryvrthin 45 calendar days. _ <br /> - I <br /> 5_Attach the gener4orforms(MPES Form 79-1257 fbr all generators that oontrlbulted to the load of IKG to this-form. i <br /> Maintain this form and the attached deneratorforms fortwo years from the date on this form. <br /> I <br /> Date of IKG Raceipt T-une of IKG RaueipL T of I Used Oooldn�q Ol <br /> ypa LJ j i <br /> r f ! <br /> &12,' l pM IKG lntemeptor/Trep Grease <br /> Rerniving i-ao7ry Name- - C� <br /> lb . i , �,k PC,x_— <br /> ReceWMa Fa(:TrtyAddn� U <br /> Tabal IKG Recehrad- El Gallons Measuri g Method Elsed` Cor?ainer Volume(lf R®qt ired)- Percentage Fin(lf Rsgtfire4- <br /> Pounds <br /> Res.r Transporter Name: VehHe Decal Number_ <br /> 7I '775 <br /> Driver Name(Prim: Reaemng FacaffV I Name(Pring): <br /> JC <br /> " J'v)(e� 8Ae, <br /> Driver SigrtBfvre Receiving FavTi4r Pepresentalive Sigrmbum:• t <br /> r <br /> li <br /> �I <br /> AVH : 01 c �H 'S 'add <br />