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D�PA,RTNQ'NI'DF OGD ANA AGRTCUZ,TUB,E 0 9 S Z ' N AHS 0 l I1=0 '6 'n o N ;a i l p a n i a a d- Me4 Poultry acid Egg Safety Branch A220 N street SaMmento,CAI 95814 (916)900-5004 79-I24 (.Esc 11/12) < 11 1Vlawifest , "edi kJi'When.Grea.se '�;'rari:�polt-t �xxstxuc�bns and .Reeeivi qg Facility Information .. _._.a ' I . I A complete Iaedi leKitchenAregse,(IKG)Transport Manifest-fox a load of II£G consists of this for�ln . ,and all generator copies froni-MP ,_Form 79-125 (Mmiffest-Inedible Kirtchen Grease Tr sport, :Generator 14&;niat1i6k,, for geiiiet stors1KG to thV1osd_'Aiternativ.eiy;tore tranT?rtear waY use other forms that eoritain all required iiaformatitolnt_ All forms in each manifest must 'lnarve the same ManLdest lumber. Transpoitors"must keep=:cosnpld6 :a ,&st4,for-:Wo years: Mant€e9t Instructions: •1_The driver of lithe IKG transport vehicle is responsible for entering all information on this farm and an MPES Form 79- X25, Manifest-Inedible"then Grease Transport;-Generator.Information, except.for in the.Receiving Facility _-Representative and Generator Representative name and sidnr Lure boxes. All entries must be in Ink and legible. The f driver must.initial.any corrections to info matron already-entered: ;;2. Enter all information in the form below for each load of IKG. Give one copk of the completed form to the receiving 3 fadilftbtkle time 67 IKG f6ceii t or mail or'del'iverthe-copytothe receMng-faci�rtywithirr l5-workdays_- 3. Enter the Manifest Number found at the,#op bf this form in the Man est'No. box.on the generator form(MPES Form 79- 125.)for eahh generator that cortttibutep to the„]oad.''All generator forms froom generators where IKG was;'collected to make up the load must have the same Manifest Number as the attached Receiving Facility Information form. ' 4_ Give the generator copy(from MPES Form 79-125)to the generltor 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 IKG to this form_ ' Maintain this form-and the attached generator fbrms for two years from the date on this,form, Date of IKG Receipt 'rwne of lKG Receipt: Typo of Used Cooking Oil C ❑ i PM IKG: 1-12 Interoeptor�Trap Grease L� FZ2c6Tving Facirrty Marne:me: Receiving FacrTity Addres*§” Total IKG Received: Gallons Measuring Meth' Used: coritainerVulume'(1 quires: Percentage Fill Of Required). V � Pounds F2egist2reU T/{r�a/nnupor rNamE VehiGe Decal Number Driver Name(Printed): -• Recemng Facirdy EZ�reeent3tive Name(Plaited):V E 4n LLMi DriverSigrrah,re_ Racetving Facility Representative Signature: II ' � I i 01 d 9S16 N AVSI : l l LI:H '6 'AON