Form Ehs 4008 - Comment Addendum - N.c. Department Of Health And Human Services

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Health Department:_______________________________
N.C. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Facility ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
DIVISION OF PUBLIC HEALTH
Date: ___________________________________________
ENVIRONMENTAL HEALTH SECTION
Status Code:____________ Time:___________________
COMMENT ADDENDUM
Water Sample taken today?
YES
NO
Name of Establishment:_______________________________________
Inspection
Pre-opening Visit
Critical Violation Visit
Location Address:____________________________________________
Re-Inspection
Visit
Other _____________
City:_______________________________State: NC Zip:___________
TEMPERATURE OBSERVATIONS
Item/Location/Time*
Temp
Item/Location/Time*
Temp
Item/Location/Time*
Temp
*
when cooling
COMMENTS
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EHS Signature:___________________________________________ EHS ID #:_____________Received by:___________________________________
Instructions:
Purpose: This form is developed to be used for making explanatory comments observed during inspections, visits and/or notices of permit actions at establishments inspected by
Environmental Health Specialists under rules adopted by the Commission for
Health. Preparation: Local Environmental Health Specialists shall complete form EHS 4008
Public
when necessary during inspections, visits and or notices of permit actions. The original and two copies will be distributed with the inspection form about which they provide comments.
Disposition: This form may be destroyed in accordance with Standard-8.B.6., Inspection Records, of the Records Retention and Disposition Schedule for County/District Health
Departments published by the North Carolina Division of Archives & History. Additional forms may be ordered from: Environmental Health Section, 1632 Mail Service Center,
Raleigh, NC 27699-1632. (Courier 52-01-00)
EHS 4008 (Revised 7/12)
Environmental Health Section

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