ENVIRONMENTAL HEALTH INSPECTION REPORT NON-SEWERED TOILETS

Health District County Date

Event GPS Lat. GPS Long Time

Street Address City Zip Code

Agency
Contact Person Telephone

Contractor License #
Contact Person Telephone

Number of Units Inspected

Unit # Condition: Satisfactory Unsatisfactory  am  pm
Unit # Condition: Satisfactory Unsatisfactory  am  pm

Taken
No Bad Out of
Unit # Full Supplies Dirty Repair Service Sticker # Released Comments

Corrective Action

Disposal Site Agreement Date

Inspected By Discussed With

EHER Form LU113