Form 79-012A(1) Inedible Kitchen Grease Transporter Registration Application - California

Form 79-012A(1) is a California Department of Food & Agriculture form also known as the "Inedible Kitchen Grease Transporter Registration Application". The latest edition of the form was released in August 1, 2018 and is available for digital filing.

Download a PDF version of the Form 79-012A(1) down below or find it on California Department of Food & Agriculture Forms website.

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STATE OF CALIFORNIA
DEPARTMENT OF FOOD AND AGRICULTURE
Registration Fee: $250.00
Meat, Poultry and Egg Safety Branch
PLUS Enforcement fee of $125.00
1220 N Street
for one vehicle per year.
Sacramento, CA 95814
(916) 900-5004
79-012A(1) (Rev. 08/18)
PERSONAL USE
Date:
INEDIBLE KITCHEN GREASE TRANSPORTER
Total Fee: $375
REGISTRATION APPLICATION
I hereby apply to register as a Transporter of Inedible Kitchen Grease in accordance with Sections 19215 through
19316 of the California Food and Agricultural Code. I agree to abide by Sections 19303(b) through 19306 pertaining
to requirements to keep and make available records for two years.
Section 19310(c)(1)(2)(3) requires that proof of liabilty insurance or a surety bond of not less than $2,000,000 be
provided prior to the issuance of the registration. Transporters operating only one vehicle of less than 10,000 pounds
GVW rating must only provide proof of liability insurance or a surety bond of not less than $1,000,000.
Please Print or Type
Name:
Phone Number:
FAX Number:
Mailing Address:
Location (if different):
City, State, Zipcode:
City, County, Zipcode:
E-mail Address:
DRIVERS' NAMES AND LICENSE NUMBERS
Drivers' Names
Drivers' License Number
Drivers' Names
Drivers' License Number
VEHICLE INFORMATION
License #
Year
Model
Make
Destination of Grease
Address of Destination
*Any change in the information contained in the license or registration application shall be reported in writing to the
Meat, Poultry and Egg Safety Branch within (10) business days of such change.
*Providing false information on applications for licenses or registration application shall be a violation and shall be
justification for denial of an application.
*I declare under penalty of perjury that the information provided on this application is true and accurate to the best of
my knowledge.
Printed Name of Applicant:
Signature of Applicant:
Mail application and $375.00 fee to: Department of Food and Agriculture, 1220 N Street, Sacramento, CA 95814.
Please make check payable to: CDFA L 90101
STATE OF CALIFORNIA
DEPARTMENT OF FOOD AND AGRICULTURE
Registration Fee: $250.00
Meat, Poultry and Egg Safety Branch
PLUS Enforcement fee of $125.00
1220 N Street
for one vehicle per year.
Sacramento, CA 95814
(916) 900-5004
79-012A(1) (Rev. 08/18)
PERSONAL USE
Date:
INEDIBLE KITCHEN GREASE TRANSPORTER
Total Fee: $375
REGISTRATION APPLICATION
I hereby apply to register as a Transporter of Inedible Kitchen Grease in accordance with Sections 19215 through
19316 of the California Food and Agricultural Code. I agree to abide by Sections 19303(b) through 19306 pertaining
to requirements to keep and make available records for two years.
Section 19310(c)(1)(2)(3) requires that proof of liabilty insurance or a surety bond of not less than $2,000,000 be
provided prior to the issuance of the registration. Transporters operating only one vehicle of less than 10,000 pounds
GVW rating must only provide proof of liability insurance or a surety bond of not less than $1,000,000.
Please Print or Type
Name:
Phone Number:
FAX Number:
Mailing Address:
Location (if different):
City, State, Zipcode:
City, County, Zipcode:
E-mail Address:
DRIVERS' NAMES AND LICENSE NUMBERS
Drivers' Names
Drivers' License Number
Drivers' Names
Drivers' License Number
VEHICLE INFORMATION
License #
Year
Model
Make
Destination of Grease
Address of Destination
*Any change in the information contained in the license or registration application shall be reported in writing to the
Meat, Poultry and Egg Safety Branch within (10) business days of such change.
*Providing false information on applications for licenses or registration application shall be a violation and shall be
justification for denial of an application.
*I declare under penalty of perjury that the information provided on this application is true and accurate to the best of
my knowledge.
Printed Name of Applicant:
Signature of Applicant:
Mail application and $375.00 fee to: Department of Food and Agriculture, 1220 N Street, Sacramento, CA 95814.
Please make check payable to: CDFA L 90101

Download Form 79-012A(1) Inedible Kitchen Grease Transporter Registration Application - California

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