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2. CAMP SCHEDULE

1. CAMP RULES

3

79

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3. CAMP BROCHURE

INSPECTOR'S SIGNATURE

ASSURANCE OF CONFIDENTIALITY

All information provided will be accorded confidential treatment and will be used for statistical purposes only. the statistics will be presented in such a manner that no individual person or facility can be identified.

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GRAND TOTAL

43-46

h.

TOTAL

60-82

SM-750-3 (Page 1) 0-73

OMB NO. 68-S73043
Approval Expires January 1974

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56

59

793

2

Covered by No. Sa above.

2017]

Don't include hours for eating and sleeping

7. COMMENTS

HSM-750-3 (Page 2) 6-73

SIGNATURE

TASSURANCE OF CONFIDENTIALITY

All information provided will be accorded confidential treatment and will be used for statistical purposes only; the statistics will be presented in such a manner that no individual person or facility can be identified.

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% UNSATISFACTORY

%

Day

Yr

Mo,

23-25

HSM - 750 - 2 5-73

(Page 1)

OMB NO. 68-S73043
Approval Expires January 1974

(Continued on Page 2)

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O w Not Done

NO

N/A

oO w Not Done

YES

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NO -2

N/A 1

-2

7 O

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9

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10 0

35 0

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113

Walls and Ceiling Not Easily Cleanable

11 O

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12 O

Other Improper Facilities or Operations

Describe

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85. Single Fire Exit

86.

Unmarked Fire Exits

87. Fire Extinguishers Not

Available or Improper Type

88. Fire Extinguishers Out of Date

89. Structurally Unsafe

90. Insanitary Condition of

Kitchen Area

91.

Food Adulterated or Spoiled

92. Unapproved Food Source

93.

Inadequate Facilities For
Maintenance of Proper
(Hot/Cold) Food Temps.

94.

Poisonous/Toxic Material
Improperly Stored

95.

Persons With Apparent
Communicable or Contagious
Diseases Observed in improper.
Areas

96. inadequate Hygiene of Food

Handler

97. Equipment Improperly

Constructed or Installed

98. Utensils Improperly Stored

99.

Dishwashing Facilities
Inadequate

100.

Tableware Not Sanitized

101. Single Service Articles

Improperly Stored

102.

Hot and Cold Running Water
Not Available

103.

Waterheater Without
Press/Temp. Relief Valve

104. Cross Connections

105.

Accumulation of Grease on
Food Equip., Stoves, Etc.

106.

Toilet and Lavatory with
Hot/Cold Water Not Available

107. Garbage Not Stored in

Adequate Number of Approved
Containers

108. Garbage Not Removed From

Kitchen Daily

109. Inadequate Insect and Rodent

Control

INSPECTOR'S SIGNATURE

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