21616 76TH AVE W STE 104_2FIRE PREVEITrTUIT
Serving BJI__., -----.!onds 12425 Meridian Ave S NSPECTION REPORT
SNOHOMISH CO. * '�) OEDMONDS
MT_," Mountlake Terraq,and Everett, WA 98208 0 BRIER
u M, E]WOODWAY
--the Town Of Wood'vqy Phone (425) 551�4200
0 MOUNTLAKE TERRACE
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ADDRESS: 21616 76th Avenue W, Suite 104, Edmonds, VVA 98026
BUSINESS OWNER: HOME PHONE:
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I AGREE TO CORRECT THE ABOVE VIOLATION(S) IN THE NEXT 30 DAYS
1st RE -INSPECTION
DATE DUE:
2nd RE -INSPECTION
DATE DUE:
EXTENSION
GRANTED TO:
FINAL RE -INSPECTION
DATE DUE:
VIOLATIONS
CITED:
PERSON
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INSPECTOR:
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DATE:
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VIOLATIONS
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PRE -CITATION
LETTER SENT
CITATION ISSUED
NUMBER:
4
2
6
2
6
DATE:
CODE
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DISPOSITION:
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FIRE DEPARTMENT COPY
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FIRE PREVENTION
Serving Briei; Edmonds
12425 Meridian Ave S
INSPECTION REPORT
SNOHOMISH CO.
Mountlake Terrace, and
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Everett, WA 98208
VEDMONDS
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LOCATION: 21616 76th Avenue W
FREQUENCY I STATION & SHIFF'*"
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BUSINESS NAME: Ae-4ibio [—Xe(ap-if
PHONE: 2064053238
SCHEDULED
DATEDUE 1` 09/01/12
MAILING 21616 76th Ave W #IM-
LIFIR � 593 9156
ADDRESS:
Edmonds 98026
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ANNUAL
HAZARDS FOUND AND LOCATIONS COMMUNICATIONS
2
2
3
3
4
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6
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7
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I AGREE TO CORRECT THE ABOVE VIOLATION(S) IN THE NEXT 30 DAYS X
lst RE -INSPECTION
DATE DUE:
I
2nd RE -INSPECTION
DATE DUE:
1
EXTENSION
GRANTED TO:
FINAL RE -INSPECTION
DATE DUE:
VIOLATIONS
CITED:
PERSON
CONTACTED:
PERSON
CONTACTED:
PERSON
CONTACTED:
1
INSPECTOR:
INSPECTOR:
INSPECTOR:
2
DATE:
2ATE:
DATE:
3
VIOLATIONS
1 5
VIOLATIONS
1 5
PRE -CITATION
LETTER SENT
CITATION ISSUED
NUMBER:
4
2
6
2
6
DATE:
CODE
SECTIOM
5
3
7
3
7
RETURN RECEIPT
RECEIVED
6
4
8
4
8
DATE:
DISPOSITION:
LETTER NEEDED [] YES El NO
I LETTER NEEDED F] YES El NO
8
FIRE DEPARTMENT COPY
SNOHOMISH CC
FIRE
DIST
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12425 Meridian Ave S
Everett, WA 98208
Phone (425) 551-1200
Fax (425) 551-1272
LOCATION: 21616 76th Avenue W
BUSINESS NAME: Wa Center forPain Mgmnt PHONE: 4257741538
MAILING 21616 76th Ave W tpo t 0),
ADDRESS: Edmonds 98026
BUSINESS OWNER: Hong, Hung Dr. HOME PHONE: 5035236766
EMERGENCY-1: Hanson, Rick /Bid Maine "5"')HOME PHONE: 4254614324
KEY ACCESS-2: HOME PHONE:
Serving Briet; Edinonds
Mountlake Terraceand
the Town of Woodway
www.FireDistrictl.org
PERSON CONTACTED: __,> d:;,., er c.,
NAME OF INSPECTOR: I —A
FIRE
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FIRE PREVENTION
INSPECTION REPORT
OEDMONDS
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OWOODWAY
[I MOUNTLAKE TERRACE
0 UNINCORPORATED
FREQUENCY I STATION & SHIF"*'
731 16 A
SCHEDULED
DATE DUE 11' 09/01/12
UFIR � 593 9156
ACTIVE
CURRENT
CITY YES NO
BUSINESS r'17",
LICENSE 'Dk El
INITIAL INSPECTION DATE
0
ANNUAL
HAZARDS FOUND AND LOCATIONS COMMUNICATIONS
2
2
3
3
4
4
5
5
6
6
7
7
I AGREE TO CORRECT THE ABOVE VIOLATION(S) IN THE NEXT 30 DAYS X
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lst RE -INSPECTION
DATE DUE�
_.—PERSON
2nd RE -INSPECTION
DATE DUE;
EXTENSION
GRANTED TO:
FINAL RE -INSPECTION
DATE DUE:
VIOLATIONS
CITED:
PERSON
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CONTACTED:
PERSON
CONTACTED:
1
INSPECTOR,
INSPECTOR:
INSPECTOR:
2
DATE:
DATE:
DATE:
3
VIOLATIONS
1 5
VIOLATIONS
1 5
PRE -CITATION
LETTER SENT
CITATION ISSUED
NUMBER:
2
6
2
6
DATE:
CODE
SECTION:
5
3
7
3
7
RETURN RECEIPT
RECEIVED
6
4
18
4
18
DATE:
DISPOSITION:
7
LETTER NEEDED [] YES NO
LETTER NEEDED YES NO
FIRE DEPARTMENT COPY