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STAT) .OF CALIFORNIA y DEPARTMENT OF FOOD ANA AGItICTJ�.1,CTRE 0 9 5 l '°N=WH S O l l=L l OZ-4 '6 n o N=a ua l p a n l a°a d Meat,Poultry and Egg Safety Branch S i2a0 NStreet Mani fesf fro.: Sacramento,CA 95814 �I (916)900-5004 79-124 (135P_11/12) Mani' est. luetiili�eitclien Cee 7iran'sport ' Instruction' s and Receiving �aciiity'Informatlion A complete Inedible Kitchen Grease tIIK_) Tra.port Manifest.for a load of)]KG consists of this form ;and all generator copies fromMPES'lorm 79-125 (Manifest-Inedible Kitchen Grease T ranspoi-t, :Generator]Criformation�'fof geiiei-atoh,Wi f`eoiatril'b'iati� G tcs the'10 tL Alternativeiy,:the transporter may use other forms that contain A required information. .,All forms in each manifest must 'have the same 4audest Number. Transpoirters mustkeep:compleLea�lgtianifests Rif-ti,o years:. Manffest Instructions: 1.The driver of the IKG transport vehicle Is responsible for''66tering all information on this form and on MPES Form 79- Manifest- Inedible Kitchen Grease Transport,-Genetator-Inform-ation, except.for in thei.Receiving Facility Representative and Generator Representative name and signature boxes. All entries must be in ink and legible. The =driver must,initiallany con-ections to information alteadyenl~ered;,_ 12. Enter all Information in the form below fol each load of IKG-, Give one copy of.tile completed form to the receiving facir y'afthe tithd of[KG receipt or mail or tleliver the copy to the recelving.facir wrthln i 5 work..days.- : _ -I 3 Enter the Manftst Number found.at the top�of this form in the Man�fiest�No. box6n the generator form(MPES Form 79- 125)for each generator that contributes to the;load.' All generator form's fromgenerators where IKG was collected to make up the load must have the same Manifest Numbee asihe..attached Receiving Facility Information form- 4. Give the generator copy(from MPES Fort 79-125)to the generator at the time.vf IKG collection or mail'or deliver the copy to the generator within 45 calendar days. i 5.Attach the gen'erator forms (MPES Forrrl 79-125)for all generators that contributed to the load of IKG to this form. Maintain this forret and-the attached generator forms for two years from the daze on this.form. Date of IKG Receipt I Time:of IKG RQeCslptf` I Used Cooking Oil Typo ofLJ i IKG: Intem ptodTrap Grease i. RecFix6ng l:acirrty Name / V. I Receiving Fan -AddreztE�.''— 1 Total IKG Rece ' .- ✓� Measuring Met�Frbd sed; Cont3inervolumA(If,Raquimdy Percentage F111(if Required)_ i Gallons Pounds kegis eered Transporter Name: I Vehicle Decal Number- Driver Name ring: Receiving Facility Representa&a Name(Pdnt@d): Cl Driver ignature' Receivin Facirrty Signature: j 1 9 'd " 9SI6 '°N AW : ll LIE '6 'AON