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UNCLASSIFIEDBLAW ENFORCEMENT SENSITIVE (When Completed) <br />Criminal Organization <br />(If needed, use "Other Notes Section" on last page to document more than 3 organizations.) <br />Does the facility collect criminal organization or security threat group information? <br />f Yes C No <br />Name of Criminal Orc anization Category Leave blank Or anization Level Leave blank OID Leave blank <br />l� ..� �. 1 -1 F I <br />Name of Criminal Organization, Category Leave blank Or anization Level Leave blank OID Leave blank <br />_,.T�__ <br />Name of Criminal Organization Cat eclary Leave blank Ors ani�zat`e_a_n_Level Leave blank OID leave blank <br />FOOD SERVICE <br />Sanitation Requirements <br />Has the facility been inspected by an external entity within the past 12 months to ensure that the food service and <br />equipment meets established health, sanitation, and safety protocols? <br />(` Yes C° No <br />If 'Yes', Date of Inspection <br />Were any violations identified? <br />C Yes C No <br />Have those violations been corrected? <br />C' Yes C' No <br />Was the facility re -inspected to ensure the violations were corrected properly? <br />C Yes ( No <br />NOTICE, This document is intended FOR OFFICIAL USE ONLY and may contain LAW ENFORCEMENT SENSITIVE OR CONFIDENTIAL information <br />which is for the sole use of the intended recipient(s). Any unauthorized review, use, disclosure, or distribution is prohibited. If you are not the intended <br />recipient, please contact the sender and destroy all copies of this document. Any Protected Health Information contained in thls document is to be used <br />only to aid in providing healthcare services to federal prisoners, Any other use is a violation of Federal HIPAA Law andfor the Privacy Act and will be <br />reported as such. <br />UNCLASSIFIEDYLAW ENFORCEMENT SENSITIVE (When Completed) <br />Page 19 of 27 <br />Form LISM-21a <br />Rev. 02125 <br />