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Tyne of Inspection NCDA&CS,VETERINARY DIVISION <br /> New ❑ P.O.BOX 26026,RALEIGH,NC 27611 INDOOR ❑ <br /> Annual ❑ r Phone: 919/733-7601,Fax: 919/733-2277 OUTDOOR ❑ <br /> Follow-Up e! BOTH <br /> (Prev. Inspection Date) <br /> Complaint It/ ANIMAL WELFARE INSPECTION <br /> Courtesy ❑ <br /> Random ❑ <br /> GPS Coordinates - N: m■ W: m <br /> QBSP Number— =— I _tt <br /> BUSINESS N ME: -a ,�%r LICENSE#: <br /> Qom: <br /> ADDRESS: t n <br /> TELEPHONE: f- 2 9 O � • ._ COUNTY <br /> TYPE FACILI : Animal Shelter p--Boarding Kenni? ❑ Dealer ❑ Pet Shop ❑ PuiAic Auction ❑ <br /> Number of Primary Enclosures c' Animals Present: Dogs Cats ,�rjC�„•e `' <br /> Inspector.- " Mirk'W'in box if ade� uate -•Circle itei<n number if inadequate.11 Use NA if not applicable <br /> STRUCTURE SANITATION SPECIAL ITEMS <br /> Housing Facilities L11. Waste Disposal Records <br /> 1. Structure& Repair 12. Odor g (23. Description of Animals <br /> 2. Ventilation&Temp. V. Ceiling,,Wall,Floors 24. Records/Vet Treatment <br /> $0. Lighting 14. Primary Enclosures 25. Origin/Disposition <br /> 4. Ceiling,Wall,Floors K 15. Equipment& Supplies M. 4bwwding4mml) <br /> 5. Storage 6. Washrooms,Sinks,Basins <br /> rat 6. Water Drainage 17. Insect/Vetmin Control Transportation <br /> 18. Building& Grounds V27. Care in Transit Discussed <br /> Primary Enclosures iUSBANDRY <br /> 7. Structure& Repair )(19. Adequate Feed/Water ' Veterinary Care <br /> 8. Space V20. Food Storage 28. Isolation Facility <br /> 9. Ventilation&Temp. 21. Personnel 29. No Signs of Illness/ <br /> 10.Adequate Shelter f22. Animals' Appearance Treated <br /> Item Number Explanation of Inadequacy(circled items above)And Date Corrections <br /> Recommendation For Com fiance Must Be Completed <br /> VAPPROVED ❑ DISAPPROVED Date: �� ! �� =—'" Time: <br /> Veterinarian: , 12 �kJ ---^•. Telephone: (�� , 5V4- .2 3 29 7 <br /> ' v ! ,� 'r <br /> AW-2 s ' <br /> nspector nature yL b er/Author Agent's Signature <br /> Rev.7/01 White=Office Canary= Inspector Pink= Owner <br />