Environmental Health Inspection Report

Emergency Food Service

Health District: West Central (Columbus) County: Appling Date:

Facility Name: Agency:

Street Address: City: Zip Code:

Contact Person Telephone:

Type of Facility: Shelter Feeding Site Kitchen

Number of meals daily: Prepared __________ Served __________

Source of meals if not prepared on site: _____________________________________________________

Water Supply: Type: Public Water Transported Private Well

Quality: Acceptable Unacceptable Unknown
Sampled: Yes No Unknown Date sampled___________________

Sewage Disposal Type: Public Septic Tank Non-Sewered Toilet Other

Functioning: Yes No
Serviced/Clean: Yes No Service Company Contact:______________________

Food Storage: Acceptable Unacceptable

Corrections/Comments _____________________________________________________________________

Food Preparation: Acceptable Unacceptable

Corrections/Comments __________________________________________________________________

Food Temperatures (list additional locations on back): Cold-<= 41º, Hot: >= 135º
Location Food Hot Cold
_______________________________________ _______________________________ _____ _____
_______________________________________ _______________________________ _____ _____

Equipment-Utensils: Clean/Sanitized Dirty Bad Repair

Corrections/Comments _____________________________________________________________________
_____________________________________________________________________________________

Hand Washing Facilities: Acceptable Unacceptable

Corrections/Comments ___________________________________________________________________

Trash/Garbage Handling: Acceptable Unacceptable

Corrections/Comments ___________________________________________________________________

Insect & Rodent Control: Acceptable Unacceptable

Corrections/Comments ___________________________________________________________________

Orders/Instructions Given ____________________________________________________________________

Discussed With: ___________________________________ Inspected by: _____________________________

EHER Form FS101

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