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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 />Date <br />Interviewee Title <br />Zip <br />Facility Fax Number <br />Owner Name Owner Phone Number <br />Owner Address <br />City Zip Code <br />Email <br />Property Owner <br />Owner Name _ <br />Owner Address <br />City <br />Operation <br />Owner Phone Number <br />❑Mon ❑Wed ❑Fri ❑Sun Time Open <br />❑Tue ❑Thurs ❑Sat 4567891011 <br />Time Close <br />4567891011 <br />❑ 24 hours/day <br />III. Photos <br />Zip Code <br />12123456789101112 <br />12123456789101112 <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 />19 F -2 / 8 Page 1 of 4 <br />