HomeMy WebLinkAbout4. Perishable Food Donation Record FormFood Facility Operators
Food Donation Delivery Form
City of Diamond Bar • Environmental Services www.diamondbarca.gov/1139/Edible-Food-Recovery-SB-1383
20810 Copley Drive, Diamond Bar, CA 91765 • (909) 839-7000
Transported By (if other than donor or recipient):
Donated To:
I acknowledge that the food item(s) listed above meet the temperature holding requirements for
potentially hazardous foods, as defined in Section 113871 of the California Retail Food Code.
Donor Signature Date
Recipient Signature Date
Perishable Food Item(s)
(Continue Items on Back of This Page if Needed)
Quantity
(lbs.)
DONOR
Temperature
at holding
Accepted Time
Taken
RECEIVER
Temperature
at receipt
Time
Taken
YES or NO
YES or NO
YES or NO
YES or NO
YES or NO
Donated From:
Name of Facility or Event Public Health Permit #
Address Phone #
Delivered by (Print Name)
Name of Facility or Organization Public Health Permit # (if applicable)
Address Phone #
Received by (Print Name)
Name of Delivery Organization Public Health Permit # (if applicable)
Address Phone #
Delivered by (Print Name)