Record of Response to Request for Inspections

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Please contact your local fire and health authorities and COMPLETE the form as a record for who contacted.

Published in: Health & Medicine
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Record of Response to Request for Inspections

  1. 1. RECORD OF RESPONSE TO REQUEST FOR INSPECTION FIRE AUTHORITIES A. Local Authority (for example: city, town, or community Fire Dept.) Name of Person Contacted:__________________________ Date of Contact: ____________________ Name of Organization:_________________________________________________________________ Response to Request for Inspection ______________________________________________________ ___________________________________________________________________________________ B. Regional Authority (for example: county, area, or multi-county co-op Fire Dept.) Name of Person Contacted:__________________________ Date of Contact: ____________________ Name of Organization:_________________________________________________________________ Response to Request for Inspection:______________________________________________________ ___________________________________________________________________________________ HEALTH AUTHORITIES A. Local Authority (for example, city, town, or community Health Dept.) Name of Person Contacted:__________________________ Date of Contact: ____________________ Name of Organization:_________________________________________________________________ Response to Request for Inspection:______________________________________________________ ___________________________________________________________________________________ B. Regional Authority (for example, county, area, or multi-county co-op Health Dept.) Name of Person Contacted:__________________________ Date of Contact: _____________________ Name of Organization:__________________________________________________________________ Response to Request for Inspection:_______________________________________________________ ____________________________________________________________________________________ Latest Revision 06/01/09 Page 1 of 1 file: CPA Policies/Forms/Parent Files Municipal Inspection Requests

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