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r Serving Brier, Edmonds, and 12425 Meridian Ave S INSPECTION REPORT
SNOHOMT ft CO. ❑ EDMONDS
FIREMountlake Terrace Everett, WA 98208 ❑BRIER
r/ Phone (425) 551-1200 ❑ MOUNTLAKE TERRACE
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LOCATION: p
SCHEDULL28 152
BUSINESS NAME: PHONE: DATE DUE
1070 5th Avenue, S, Edmonds, WA 98020
MAILING UFIR /
ADDRESS: Forrer, Jim #206
BUSINESS OWNER: HOME PHONE:
17
EMERGENCY-1: HOME PHONE: CURRENT
KEY ACCESS-2: HOME PHONE: CITY YES NO
BUSINESS
EMAIL: LICENSE
INITIAL INSPECTION DATE
PERSON CONTACTED:
IRE SYSTEMS: �Hq 6 12:00:00 2 _ Z — (�
NAME OF INSPECit Sefvaeed
FA
HAZARDS FOUND AND LOCATIONS / COMMUNICATIONS
1
1
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11
2
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3
4.
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I AGREE TO CORRECT THE ABOVE VIOLATION(S) IN -THE NEXT 30 DAYS X
1st RE -INSPECTION
DATE DUE.
2nd RE -INSPECTION
DATE DUE.
EXTENSION
GRANTEDTO:
FINAL RE -INSPECTION
DATE DUE:
VIOLATIONS
CITED:
PERSON
CONTACTED:
PERSON
CONTACTED:
PERSON
CONTACTED::
-
INSPECTOR:
INSPECTOR:
INSPECTOR:
2
DATE:
DATE:
DATE:
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VIOLATIONS
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VIOLATIONS
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PRE -CITATION
LETTER SENT
- CITATION ISSUED
NUMBER:
4
DATE:
CODE
SECTION:
S
3
7
RETURN RECEIPT
RECEIVED
8
4
6
DATE:
DISPOSITION:
'
LETTER NEEDED ❑ YES ❑ NO
LETTER NEEDED ❑ ' YES ❑ NO