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PEMERINTAH KABUPATEN PASURUAN

DINAS KESEHATAN
UPTD KESEHATAN PUSKESMAS BANGIL
Jalan Mangga No. 548 Telp ( 0343 ) 741 639 Fak ( 0343 ) 741639
E-MAIL : pkm_bangil@yahoo.com

BERITA ACARA PEMERIKSAAN FISIK

Pada hari ini ....................................................... tanggal ...................................................................................................

Bulan ...................................................................... tahun .....................................................................................................

Telah dilakukan pemeriksaan fisik terhadap tempat pengolahan makanan :

Nama Tempat : .....................................................................................................................................

Alamat : .....................................................................................................................................

Jenis Olahan : .....................................................................................................................................

Yang dilakukan oleh petugas pemeriksa dari .........................................................................................................

.......................................................................................................................................................................................................

Kesimpulan pemeriksaan fisik terhadap tempat pengolahan makanan : ..................................

........................................................... saran perbaikan terhadap tempat pengolahan ...........................................

.......................................................................................................................................................................................................

.......................................................................................................................................................................................................

Demikian Berita Acara ini kami buat untuk dipergunakan seperlunya.

.................................................................20.................

Mengetahui Petugas Pemeriksa

........................................................ 1..............................................................
....................................................... NIP.

2. .............................................................
NIP.
........................................................
3. ..............................................................
NIP.

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