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<br />Print Date: September 12, 2005 <br /> <br /> <br />2645-1796:000 <br /> <br />Bureau of Food and Meat fuspectio <br />Attention: Records Section <br />3125 Conner Boulevard, C-26 <br />Tallahassee, Florida 32399-1650 <br /> <br /> <br />FOOD SAFETY INSPECTION REPORT <br /> <br />F,S, Chapter 500 <br />(850) 245-5520 <br /> <br />CHARLES H. BRONSON <br />COMMISSIONER <br /> <br />Firm Number: <br />Firm Name: <br />Date of Visit: <br /> <br />26451786900038 <br />HOLE IN ONE DONUT SHOP #3 <br />September 12,2005 <br /> <br />Payment Received Yes ( ) No () Refer to the Comments section for payment explanation, <br /> <br />ACKNOWLEDGMENT <br /> <br />I acknowledge receipt of a copy of this document, and I further acknowledge that I have verified the location and mailing addresses on <br />the first page of this document are correct, or I have written the correct information on the first page of this document. <br /> <br />(P~ -~ <br />-(Signature 0 DACS Representative) <br /> <br />~~nmcharge) <br /> <br />f). N ?UM 0 UJNe~ <br />(Please print name and title) <br /> <br />BRENDA PATRICK, SANITATION AND SAFETY SPECIALIST <br /> <br />Page 2 of2 <br /> <br /> <br />DACS 14205 Rev, 10/96 <br />