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DEPARTMENT OF HEALTH AND HUMAN SERVICES Food and Drug Administration

FOOD WAREHOUSE INSPECTION REPORT
1. ESTABLISHMENT NAME AND ADDRESS (Include ZIP code) 2. DATE INSPECTED

3. STATE LICENSE OR PERMIT NUMBER

4. NAME OF OWNER

5. TELEPHONE NUMBER (Include Area Code)

6. NAME OF MANAGER

7. TELEPHONE NUMBER (Include Area Code)

INSTRUCTIONS:

Answer the following questions by checking the appropriate box. Explain "No", answers on continuation sheet(s). Precede each explanation with the item number. Use "N/A" where questions are NOT Applicable.

NO. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

STORAGE CONDITIONS
Are incoming lots examined visually for damage or contamination prior to placement in storage Are food products stored off the floor and away from walls Does the firm routinely rotate stock

YES

NO

Are items damaged while in storage immediately removed, including any resultant spillage

Does firm maintain a morgue area for damaged and returned goods, sufficiently separated from main storage area Are morgue items disposed of in proper and timely manner to prevent a source of pest breeding and harborage Are fertilizers, toxic chemicals, and other potential adulterants adequately separated from human food storage areas Are rodenticides and insecticides properly used and stored Are refrigerated storage and frozen storage maintained at proper temperatures, 45 or less / 0 F or less, respectively Are cold storage units equipped with suitable thermometers

STORAGE CONDITIONS - SPECIFIC CONTAMINATION NOTED 11. 12.
Was storage area free of evidence of current insect, rodent, bird, etc., activity Were lots of products susceptible to contamination (e.g., macaroni products, cereal, nuts, popcorn, beans, flour, dried fruit, poppy and sesame seeds, rice, cornmeal, etc.) examined and found free of contamination. (List lots checked on continuation sheet)

REPACKAGING OPERATIONS 13. 14.
Are repackaging operations (if present) conducted under sanitary conditions adequate to protect the purity and wholesomeness of the finished product Is appropriate bulk container labeling information carried over to retail package PAGE 1 OF 3
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FORM FDA 2679 (8/01)
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INSPECTION CRITERIA NO. 15. 16. 17. 18. 19. BUILDING AND GROUNDS
Are outside premises free from spillage, trash, etc., which may attract or harbor rodents or other pests Is the building of suitable construction and generally in good physical repair Are open windows screened and are loading doors kept closed when not in use

YES

NO

Is interior lighting sufficient to allow adequate inspection and cleaning of premises Has firm scheduled cleaning and pest control program, including at least weekly inspections by qualified employees

TRANSPORTATION PRACTICES 20. 21. 22.
Are food delivery vehicles clean and in good repair Are foods loaded in separate vehicles from toxic chemicals or other potential contaminants Are vehicles delivering refrigerated and / or frozen foods equipped to maintain temperatures specified (See Item 9)

TOILETS, DRESSING ROOMS, AND EMPLOYEES 23. 24.
Are toilets and dressing rooms in good repair, clean, properly ventilated, and adequately separated from storage areas Are handwashing facilities clean and supplied with soap, hot water, and sanitary towels

CORRECTIONS AND SAMPLES 25. 26.
If any corrections were made as a result of this inspection or noted since previous inspection (including voluntary destructions, capital improvements, etc.) , complete Voluntary Correction section of cover sheet From FDA 481 (E) - cg If any samples were collected, list sample numbers and briefly describe samples.

FORM FDA 2679 (8/01)

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DISCUSSION WITH MANAGEMENT
Indicate individual with whom inspection was discussed. Identify official official (name and title) having authority to authorize corrections. Record any recommendations and / or warnings given, and management's response.

CONTINUATION SHEET

(Use additional sheets as appropriate)

SIGNATURE OF INSPECTOR

DATE

FORM FDA 2679 (8/01)
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