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ff, -- , .......-. .. . _-....._ .. ... _... .... ..68H "V-Nd8lZ ...Ll0Z- 'til 'IsnV..auail paAiaaa�— - f STATE OF CALIFORNIA DEPARTMENT OF FOOD AND AGRICULTURE Meat,Poultry and Egg Safety Branch, I 1220 N Street Sacramento,CA 95814 Manifest -Inedible Kitchen Grease Transport (916)900-5004 79-125 (Est I U12) Generator Information Complete forms,starring at bottom- Enter Manifest Number from MPES Form.79-124 for the load.. Provide generator with copy at rime of grease collection or deiiver'to ganeratbr—viin 45 days" A4tacl,:complefed eoplesto MPES Foini 79-124.. M.anifest.Num4r ©60,/ II Date: Generator Name: Generator Address Total IKG Collected:' Measuring MethodyUsed: Usett Cooking Oct Gallons Type of IKG: r.11 ,Interoeptor/TrapG[ea$e;... Pounds Container Capacity Of Required): Percentage F I(lf Required): 1KG Acrtl�orhed Iierxiving Faciligl am®: O R Cr�� ' TNa rim= it Transporter Name: f lam-) — S for Rep ritAtive M: ✓ Driver Signature; i I Time:.. AM jMaijdb��Number. Date: PM y: Generator Name: Generator Address= Total IKG Collected: I—I Measuring Method Used: r—I Used Cooking Oil LJ Gallons Type:of t_J Pounds IKG: O Interceptor/Trap Grease I Container Capacity,(If Requtrrs�: Porcentage Fill(if Requlred): IKG Authorized Receiving Facility Nern(x Transporter Name: Generator RepnesentaWe Name(Print): Driver Signature: Generator Representative Signature: r� Date: Time' M Manifest Number_ Generator Name- 1: Generator Address: �i Total IKG Collected: Gallons Measuring Method Used: Type of ❑ Used Cooking Oil IKG: 0 Intercepror/Trap Grease I"I „pounds 1 Container Capacity Of Required—):I Nrwntage Fill(If Required): IKO Authorized Receiving Facility Name: Transporter Name: Qanerator Rapmsentative Name(print): f' Driver Signature: Generator Representative Signature: �' Ll 'd-58ti8 'nN WdH :: "LIH til 'UnH