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STAT�.OF CALIFORNIA <br /> !il <br /> ' <br /> DEPARTMENT OF FOOD AND AGRICtJ)LT1TRE -.- <br /> 0952 '°N=Wd50 I I=LIOZ= '6 'AON=;Wl j P;U ;3;� <br /> meat,Poultry and Egg Safety Branch1. <br /> 122 'N st-evt Man1fesf No:. ��� (,> ](J <br /> Sacmaento,CA, 95814 <br /> (9167 900-5004 b 2-71, <br /> 79-124 (Est 11/12) <br /> lVianife t.= 1-kedib a xclien Grease'Tiaiiisport ] a <br /> Instructionns nd Reee ym— bac#' -Wormat ion <br /> 'A complete Inedible Kitchen.greas%e ;G)'T' otsport IVlanifest.for a load of IKG consists of this form <br /> •and all generator copies from M PESIorm 79-125 (Manifest,-Inedible Kitchen Grease Transport, <br /> :Generator Iiafginoiatiiom)foir gelrieiiatoFs•tha<fcohtHbau JKG to iheJoad_ Alternatively,the IKG, <br /> transporter may use other forms that contain all required in7formation_ All forms In each manifest must <br /> ;shave the same � <br /> MawdestN>limber. Transportoirs ivasf1.�eep=:co>mpleimanifesrts for.tWo ysaFs. <br /> Manifest lnsb ue-tiohs: ' <br /> 'i <br /> 1. The driver of the IKG transport vehicle is responsible for entering all information on thls firm and on MPES Form 79- l <br /> 12-5, Manifest- Inedible Kitchen Grease Transport;,—Generator-Information, except.for in the.Receiving Facility <br /> Representative and Generator Represenfattve name and signdure boxes. All entries must be in ink and legible. The <br /> .'driVer must initial any corrections to information already,entsmd <br /> 2. Enter all information in the form below for each load of IKG. Give one copy of the completed form to the receiving <br /> fakdlify;at the tiffie of IKG rbceipt or mail or'dollver the copy tothe rewjving-Facilfty within 15 work,,days_- i <br /> 3- Enter the Manifest Number.fiound at the. op f tris form in the Man� No, box:on the generator form(MPES Form 79- <br /> -125)for each generator that contributes to e;load.' All generator forms,from generators where IKG was collected-to <br /> make up the load, must have the same Ma (fest Number as the attached Receiving Facility Informatlon form. A <br /> 4. Give the generator copy(from MPES Fo 79-125)to the generator at the time of IKG collection or mail or deliver the ' <br /> copy,to the gene for within 45 calendar days- <br /> 5-Attach the generator forms (MPES Form 79-125)for all generators that contributed to the load of IKG to this form- <br /> Maintain this form and•the attached generator forts for two years from the date on this form. { <br /> Date of EKG Receipt i Tune of IKG ReceiptUsed Cooking Oil <br /> T <br /> ype oft <br /> AM / PM IKG- iCeptoN7rap Grease <br /> Receiving Facirity Name: _ <br /> -.�.7, <br /> Receiving Fau`TityAddreW�"" <br /> c- I � 5 <br /> Total IKG Received. Measurind Methba Used: U_britainervolume•'(lf.Raquirad)_ Percentage R1(if Required). <br /> Gallons <br /> Pounds <br /> 0 <br /> Registered Transports rNam I Vehicle D I Number. <br /> r <br /> Driver Name(Printe�): Receiving FaC+TV Repre�ntat�l a (Printed). <br /> T o'er, ,��-�. <br /> J <br /> D6verSfgmature. Receiving c�Tity Representative Signature. ,I <br /> IVI <br /> � 1 <br /> i <br /> 9 'd 9516 'ON AW : 11 LIE '6 'A ON <br />