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sTATF-.QFCALIFo1zrna, lIZl N=Wd I ZI=LI0Z. 'S 'da,`aWi j paneaazd DEPAR'T'MENT OF FOOD AND AGRICU..Lx'URE W4 Poultry and Ega Safety Branch . 17-20'N Street Manifest Flo:: � , Sacramento,CA 95814 � � C-707Fa (916)900-5004 79-124 03A 11/12) Manifest Inediblej kitchen' G>�-e� e r ra- nsport Instruc Ons and Recei ag Tac ty Information A complete Inedx'ltle T itche>�G>cease G)T ansport Manifest.for a load of 10KG consists of this fore n .and all generator copies from MPESForlm 79-125 (Manifest-Inedible Kitchen Grease Transport, Generator 'tWifUdAtribitte]EKG to transporter looaoy nsae otherof�o>Inoots t_biat contain all required finforn�ati g� Alternative3y,th'e-l�G, on. All forms in each manufest must R ,have the same 1Vlan est Number_ ' '>raosporters locust keep-:complete�maniifests fbftwo years: Manifest Instructions: 1. The driver of the IKG transport vehicle is responsible for entering all linforrni2 'on on this"4orm and on MPFS Form 79- 125, Manifest-Inedible IGtchen Grease Tianspo.M--.Generator-(nformadon, except.for in the.Receiving Facility :Representative and Generator kepresentativ6 name and signature boxes. All entries must be in ink and legible. The L� .-driver must initial-any corrections to information already,entered. i 2. Enter all information in the form below for each load of IKG. Give one copy of the completed form to the receiving 3j facility t the tilt of IKG receipt or mail or'deliver the copy to-the receiving-facirity within 15 work,.days: � 3. Enter the Manifest Number found at the,top of this form in the Manifest No- box.on the generator form(MPFS Form 79- 125)for each generator that contributes to the,;toad_' All generator forms from generators where IKG was collected to `I make up the load must have the same Manifest Number as the attached Receiving Facility Information form- ' I 4. Give the generator copy(from MPES Form 79-125)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 generator forms (M-PES Form 79-125)for all generators that contributed to the load of IKG to this form. Maintain this form and-the attachetl generator forms for two years from the date on this,form. Dab'of IKG Receipt Tme of IKG R�eeexipt Type Used Cooking ail AM PM IKG= Irrterueptvr/Trap Grease Receiving Facirr(y Name: I Racaiving Pso tyAddmsds'�J/j 7ota1 IKG Received: Measuring Method Used: Container Volume'(If Required): Percentage Fill(If Required); � Gallons r, VLlPounds Registered Transporter Name: Vehicle petal Number �d Driver Namo Tinted): Receiving Fablily Repn�entative Name(Printed): DriverSignature: Recelving Facility Representative Signature: S 'd H98 '°N &Hz l LlH 'S d@S