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<br />Food Service Establishment <br />Survey Inspection Form <br /> <br /> <br />Inspector Name _____________________________ Date ___________________________ <br />Inspector Signature _______________________________ <br />Interviewee Name _________________________ Interviewee Title ____________________ <br />Comments/Notes/Potential Concerns: <br />_____________________________________________________________________________ <br />_____________________________________________________________________________ <br />I. Establishment Information <br />Facility Name ___________________________________ <br />Street Address _______________________________________________________________ <br />City ______________________________________________ Zip Code__________________ <br />Doing Business As (DBA) _______________________________ <br />Facility Phone Number ___________________ Facility Fax Number _____________________ <br />Email_________________________________ <br />Facility Owner <br />Owner Name _________________________ Owner Phone Number _____________________ <br />Owner Address _______________________________________________________________ <br />City ______________________________________________ Zip Code __________________ <br />Email_________________________________ <br />Property Owner <br />Owner Name _________________________ Owner Phone Number _____________________ <br />Owner Address _______________________________________________________________ <br />City ______________________________________________ Zip Code __________________ <br />Email_________________________________ <br />Operation <br />Time Open <br />Mon Wed Fri Sun <br />4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 :30 <br />Tue Thurs Sat <br /> <br />Time Close <br /> <br />4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 :30 <br /> <br /> 24 hours/day <br /> <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 />Page 1 of 4 <br />City Council43610/21/2025 <br /> <br />