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l�T�..QF CAL.JFO DF�'ARTWNT OF FOOD AND AGRICULTURE 6 8 0 Z '°N=W d 8 l Z =L.l 0 Z- 'til ' n d,z u 1 p a n a n a�� Nfeat,Poultry and Egg Safety Branch 1220 N Street Manftest No.: U U( G S� Sacramento,CA 95814 21 (916)900-5004 79-124 (Est 11/12) Man kst nedible' lGi c"he>n Grease Tx'ai %isport Instructions and Receiving Facility Mformation 'A cowlete•Intedi"ble Kitchen;Grease(UC,G)Tiransport Manifest.for a load of IKG cousiists of this form And all generator copies from NIFES Form 79-1.25 (Manl£est-Inedible Kitchen Grease Transport, `Generator 1nf6rxi ation)for generators thAf cotoitriblittkU(C to the'lo9& Aitentatively;the-TKG, transporter may use other forms that contain all required information. All forms in each manifest must 'have the same M ` anifestNtliimber• �'ranspolrters must keep::cQhnpleted•tmanifests for:t-Pi*o years.- Manifest ears:Manifest Instructions: 1_ The driver of the IKG transport vehicle is responsible for entering all information on this form and on MPES Form 79- :125, Manifest- Inedible Kitchen Grease Transport;-Generator.Information, 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 initial any corrections to information already..entered .,2. Enter all information in the form below for each load of IKG. Give one copy of the completed form to the receiving fadrk)(atthe fte dfreceiptor mail or deliver the copy to the receiving-facility within-15-work,.da s: 3. Enter the Manifest Number found at the. top bf this form in the Mangy pstNo. box on the generator form'(MPES Form 79- j 125)for each generator that contributes to theiload.' All generator forms from generators where 1KG 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 MPP-S 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. ' 9 5, Attach the generator forms (MIRES Form 79-125)for all generators that contributed to the load of IKG to this form. Maintain this form and the attached generator forms for two years from the date on this form. i Date of IKG Receipt Time of IKG Receipt , � Used Cooking Oil Type of 00 AM � IKG_ r-A Irrterceptorll-rap Grease Receiving Facility Namo: 1^�• RaCeiving Fac7dyAd °,.,.." it • ///� ,+/�( �/� I (��^^^/1/Imo, /(/�/L '/�//�//� `/) J S l IKG Received- MeaSwring Metfi6d Used: Container Volume(If Required): Percentage Flt(If Required), - Gallons 6 () C> Pounds SrensporrtterName: Vehicle Decal Number. Receiving Facility Representative Name(Printed): Receiving Facility Representative Signature: J ,l 91 'd SM 'ON Wd8Z Z L [0Z til 'end