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L.,.:f1-MLX V ver AND AGXiICTILTURE W4Poultry aud�Egg Safety Branch 0 9-S Z '°N W H S O : I I L I O Z ,, '6 'AON a W i l p a n i a aO 1120 N street Manifest No.: Q ZE SacrmeE to, CA 95814 (916)900-5004 - 79-124 Mst 11/12) Mar t-�• nerl Xil6 T 'teh.en Gieaserari`'port Im-StmCUOns and ReceivilM Faefflty Information •'A Coen lete edible Kit P - Chen grease )Transport Manifest,for a load of II -� KG consists of this form, ,and all generator copies from MPESIForm 79-725(Manifest-Inedible Kitchen Grease Trs>asport, -Gelaeiratolr Xriformalionfor .giene`satoli-S'th&fMitiibnt G tai tb�e-lo'gd. Aaterttatively;the 17�G, transporter I%ap nse other f9rms that contaft all required.information- A19 forms In each manffest must %ave the same 1Vla est Xum6er. ' ']rains ortelrs most l ee 'c' auifests for=ti6o P p. omplele 'xgi `I Manrffeat Instfluct;o>ns: _ I. 1_The driver of this IKG transport vehicle is responsible for entering ali informAon on this form and bn MPES Por-n 7,q- 1.2-5, Manifest- Inedible Wtehen Grease Transport—Generator.Information, except for in the.Receiving Facility Representative and Generator RTr — epresentative name e'ncf signature boxes_ All entries must be in ink and legible_ The driver must,inifiatany correctons to information already,".red: -i2. Enter all information in the form below for each load of IKG. Give one copy of the completed form to the receiving taciWthe time lot IKG receipt or mail or-deliver the copy Dot1-Ie recetving iacilrlg within 15-work;.days_ 1� fj ,-!3. Enter.the Manifest Number found at the,top,0f this form in the Mame No, box,on the generator form(MPES Form 79- � 12 )for each generator that contributes to tY�e,loa0, -All generate rforms from 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 7125)to the generator at the time of IKG collection or mail or deliver the copy to the generator within 45 calendar days_ 5_Attach the gen�rator forms(MPES Form 79-125)for all generators that contribt fed to the m_ load of IKG to this for Maintain this form,and-the attached generatorforms for two years from the date on this form. DateQf IKG Rac2ipt ime of IKG Receipt Type used cooking oil i ArM 10M/ IKG_ Intenxpror[Trap Greasa �J' Rec&rving-FaoiWNarrie: - -•- -.., _ � .. .. _ ,.. i'i Receiving Facility Addres& Total IKG Received: Measuring ethocl Used; Corirainervvluma If Required): 1 i; /1 Gallons �J c�( Q = Percentage Fill(If Required): Pounds )00 71�5 Registered Transporter)Name-Name- Vehicle D ...ecel Number 7252 4 Driver Names(Printed): Receiving� Facirdy Representnf ve Name(Printed):�. it privet Signature: R®c®rvin Pe g Feq Illy prssentativeS- nature: i Z d 9SI6 'ON NW : l l LIE '6 "ON