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Office of the City/Municipality Health Office

OFFICIAL RECEIPT
Received from
(Name of Owner)
Owner of
(Name of Establishment /Ambulant Vendor)
On the following food stuffs /products /utensils.
Date

PRODUCTS UNIT QUANTITY


1.
2.
3.
4.
5.

For laboratory analysis in bureau of Food & Drugs Lab. / DOH Accredited Laboratory or
for condemnation /banning from sale as per P.D. 856.

Time of collection:

Sanitary Inspector

Acknowledge by

Product Owner /Seller

Witnessed by:

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