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Get DA 5162-R 2001-2024

U.S. DOD Form dod-da-5162-r ROUTINE FOOD ESTABLISHMENT INSPECTION REPORT For use of this form see TB MED 530 the proponent agency is OTSG. 1. VIOLATIONS List critical first. b. REPEAT c. REFERENCE PARAGRAPH FROM d. VIOLATION DESCRIPTION/REMARKS/CORRECTIVE ACTIONS TB MED 530 DA FORM 5162-R OCT 2001 DA FORM 5162 AUG 1991 IS OBSOLETE. e. ESTABLISHMENT NAME 3. PURPOSE 4. RATING 5. FOLLOW-UP INSPECTION REQUIRED ROUTINE EXCELLENT FOLLOW-UP SATISFACTORY SELF EVALUATION 6. NUMBER AND TYPE OF VIOLATIONS NO CRITICAL YES REINSPECTION DATE YYYYMMDD WAREWASHING DATA 8. REFRIGERATOR/FREEZER UNIT TEMPERATURES Type F COLD OR HOT PHF Food Location a* MANUAL 1 SANITIZING TEMPERATURES F AND LOCATIONS 2 CHEMICAL SANITIZERS Type and Concentration b. MECHANICAL 1 WASH CYCLE TEMPERATURE F 2 FINAL RINSE TEMPERATURE F Concentration 4 FINAL RINSE TIME Seconds 10. CORRECTED BY Initials/Date PAGE 1 OF 2 USAPA V1. 00ES 11a* INSPECTOR S NAME AND SIGNATURE 11b. DATE OF INSPECTION 11d. INSPECTOR S UNIT 11c* TIME OF INSPECTION 11e. UNIT S TELEPHONE NUMBER 12a* ESTABLISHMENT REPRESENTATIVE S NAME AND SIGNATURE 12c* DATE RECEIVED YYYYMMDD. ESTABLISHMENT NAME 3. PURPOSE 4. RATING 5. FOLLOW-UP INSPECTION REQUIRED ROUTINE EXCELLENT FOLLOW-UP SATISFACTORY SELF EVALUATION 6. NUMBER AND TYPE OF VIOLATIONS NO CRITICAL YES REINSPECTION DATE YYYYMMDD WAREWASHING DATA 8. REFRIGERATOR/FREEZER UNIT TEMPERATURES Type F COLD OR HOT PHF Food Location a* MANUAL 1 SANITIZING TEMPERATURES F AND LOCATIONS 2 CHEMICAL SANITIZERS Type and Concentration b. NUMBER AND TYPE OF VIOLATIONS NO CRITICAL YES REINSPECTION DATE YYYYMMDD WAREWASHING DATA 8. REFRIGERATOR/FREEZER UNIT TEMPERATURES Type F COLD OR HOT PHF Food Location a* MANUAL 1 SANITIZING TEMPERATURES F AND LOCATIONS 2 CHEMICAL SANITIZERS Type and Concentration b. MECHANICAL 1 WASH CYCLE TEMPERATURE F 2 FINAL RINSE TEMPERATURE F Concentration 4 FINAL RINSE TIME Seconds 10. CORRECTED BY Initials/Date PAGE 1 OF 2 USAPA V1. 00ES 11a* INSPECTOR S NAME AND SIGNATURE 11b. DATE OF INSPECTION 11d. INSPECTOR S UNIT 11c* TIME OF INSPECTION 11e. UNIT S TELEPHONE NUMBER 12a* ESTABLISHMENT REPRESENTATIVE S NAME AND SIGNATURE 12c* DATE RECEIVED YYYYMMDD. ESTABLISHMENT NAME 3. PURPOSE 4. RATING 5. FOLLOW-UP INSPECTION REQUIRED ROUTINE EXCELLENT FOLLOW-UP SATISFACTORY SELF EVALUATION 6. NUMBER AND TYPE OF VIOLATIONS NO CRITICAL YES REINSPECTION DATE YYYYMMDD WAREWASHING DATA 8. REFRIGERATOR/FREEZER UNIT TEMPERATURES Type F COLD OR HOT PHF Food Location a* MANUAL 1 SANITIZING TEMPERATURES F AND LOCATIONS 2 CHEMICAL SANITIZERS Type and Concentration b. MECHANICAL 1 WASH CYCLE TEMPERATURE F 2 FINAL RINSE TEMPERATURE F Concentration 4 FINAL RINSE TIME Seconds 10. .

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