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Food Service Establishment <br />Survey Inspection Form <br />Inspector Name <br />Inspector Signature <br />Interviewee Name <br />Comments/Notes/Potential Concerns: <br />I. Establishment Information <br />Facility Name <br />Street Address <br />Citv <br />Doing Business As (DBA) <br />Facility Phone Number <br />Email <br />Facility Owner <br />Owner Name <br />Owner Address <br />Citv <br />Email <br />Property Owner <br />Owner Name <br />Owner Address <br />Citv <br />Email <br />Date <br />Interviewee Title <br />Zip Code <br />raciiity rax Number <br />Owner Phone Number <br />Zip Code <br />Owner Phone Number <br />Zip Code <br />Operation <br />❑Mon ❑Wed ❑Fri ❑Sun Time Open <br />456789101112123456789101112 <br />❑Tue ❑Thurs ❑Sat Time Close <br />4567891011 121 234567891011 12 <br />❑ 24 hours/day <br />III. Photos <br />❑ Front of Facility <br />Image # <br />❑ Greatest Grease Producing Kitchen Equipment <br />Image # <br />❑ Grease Trap <br />Image # <br />❑ Grease Interceptor or Suitable Location <br />Image # <br />❑ Other <br />Image # <br />❑ :30 <br />❑ :30 <br />Page 1 of 4 <br />