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ST-ATF-OF CALIFORNIA S ti LIN 8 'g a j a w i l p a A i a a <br /> DEPART x OF F— AND AGRICU.G <br /> Mtn Pouiizy and F,gg Safety Srmch l <br /> IMO N Street - Manifest No;:' fie— p W <br /> Savraieato,CA, 95814 FE ' Q 9 201? <br /> (916 905044 .. � <br /> 79-124 (EsL 1 M2-) IWARONW,4TAL l•WV1-Ti H <br /> Mani.f,est-lued1ble-Rltchen Grea:e 'I'x port - <br /> Inructionsand Reeew* in TacYlity Informatiola L <br /> � <br /> A coxuplete InedWe]Kxtcbrek�rease fMIG.�1rsn_porfi Manifest for a Toad of TTG•consists ofthis form <br /> ,and aU geneaator copies froffi MPES Form 79-125(Manifest-Inedble Mtchcu Grease Taanspor4 <br /> Generator Inforniationy for generators that U6Abdbflite ISG to'theJoad, A&ernat%v ,_Ihe AKG , <br /> transporter may use other forms that Correin an reqMbred kufbrbuoUon_ AU fox3m bi each mmaifest mast <br /> "have fhe same Manifest N=ber. nspo><bets rouusf keep camp�etedznauirlrests for.two pests. I <br /> Manifest Instructions: - <br /> JI <br /> 1.The driver of the IKG transport vehicle is responsible for entering all infomration on this form and on MPES Form 79- <br /> .12.5, Manifest-InedUe ICrt en Grease TTansport, Generator Infarmafion,:zxc ept for in the Receiving FacTrty i <br /> Represenfafive and Generator Represm <br /> entative nae and sigf afturaboxes. All entries must be in ink and legibly The <br /> dffver must inWal any correctons.to infarrnagon already enured, <br /> 2 Enter all iRfomis: on in the form below for each load of IKG_ Cave one oppy of the completed form to the receiving. <br /> faciTrty attire time of IKG reobipt or mail or defiverthe copy b-the e receiving facifrtywithin-15-work.days_ 1 <br /> _3_Fatter the Manffest Number found at the top bf this form in the Manifest,No_bOxOn the generator form(MPES Form 79- f <br /> -125)for each generatorthst caanlxrbutes to thp-loaci All generborfonns from gfnerators where IKG was collected to <br /> make up the load must have the same Manifest Number as the attached Recelvmg Facility Information fbm-L <br /> 4. G•nre 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 79-125)for all ganerators that contributed to the load of lKG to this form. <br /> Maintain this form and the attachsd generatorforms fortwo years from the date on this form. <br /> I <br /> Date of XG RL- 2 pt 7une of 11Q3 Receipt Used Oootmq OU <br /> T' Wype <br /> PM IKG Rj lnterceptodTrap Gose <br /> Fxec2li.n,g FacORy Naim <br /> Reco mg FaaTRyAddres!s— f �. <br /> L Oj �- <br /> Total IKG RecEnr /' Measurrrrg Method Used: G-O=Zrler Velume(If Required)- Pereantage FYII(If R-p-_d)' <br /> j �AorGS n <br /> V. <br /> Pounds I f 11 ��rC� 3 / <br /> I� SiaredTrm=portarName: Vehicle Decal Number_ _ <br /> Driver Name(Pnrr�= PtacZving Fatuity Repre-sardafive Narne(Prurt ; <br /> i)rivetSignau= - Rec6Mrtg RndMy Rep esanpUva S1gnnhua:• <br /> D ' <br /> L 01VR '°N WdtiO : S LIOZ 8 q,j <br />