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27. Yes ❑ No Is at least 16" of separation or proper barriers 16" tall provided between all food <br /> preparation sinks and any source of contamination? <br /> 28. ❑ Yes qANo Is at least 16" of separation or proper barriers provided between all produce preparation <br /> sinks and raw meat, poultry, and or seafood? <br /> 29. la'Yes ❑ No Are 16" high splash guards installed between all sinks that are less than 16" apart? <br /> 30. Ja'Yes ❑ No Are soap and paper towel dispensers installed inside the splash guard area at all <br /> handwash sink locations? <br /> 31. Ir Yes ❑i No Are all handwash sink basins at least 10" long by 10" wide and 5" deep? (Required) <br /> 32. likes 0INo Do you have a designated mop sink? (Required) <br /> 33. Cd'Yes ❑I No Is the mop sink located so food and equipment are not contaminated when used? <br /> 34. ❑ Yes ©4lo Does the mop sink have a vacuum breaker installed? <br /> 35. ❑ Yes okClo Will a chemical dispensing system be installed at the mop sink? <br /> 36. ❑ Yes UI No CI'N/A If a soda fountain system is used, is a reduced pressure backflow assembly <br /> (RPBA) installed and tested? <br /> 37. ❑ Yes ❑ No IN/A If a soda fountain system is used, are all pipes and fittings used downstream of <br /> the reduced pressure backflow assembly (RPBA) non-corrodible? (copper or brass are prohibited) <br /> 38. i/Yes Cl No Is all equipment commercial grade, NSF certified or equivalent? (Required) <br /> 39. ❑ Yes Gkilo Will any food be stored or prepared at another location? If yes, list name and address <br /> where food will be stored or prepared: <br /> 40. ❑ Yes LIFNo Will any food be cooked or hot held unattended (i.e. overnight or more than 2 hours of <br /> unattended cooking)? If yes, the questionnaire for cooked or unattended food must be completed. <br /> 41. ❑ Yes frNo Will there be any cooking or food preparation outside the establishment?All locations <br /> must be clearly marked on floor plans. <br /> 42. ❑ Yes cV o Will any food of animal origin be undercooked at the customer's request, such as steaks, <br /> eggs, or hamburger? If yes, list: <br /> Environmental Health Division <br /> 3020 Rucker Avenue, Suite 104 ■ Everett, WA 98201-3900 ■ fax: 425.339.5254 ■ tel:425.339.5250 /� <br />