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HomeMy WebLinkAbout2016 May 27 - Copy of Tobacco Compliance Check Form� 05/Z7/16 01:56AM HP LASERJET FAX p.01 i '•••`-• ""'.�1 u�'� , 1 UD8CCt1�U�l�llli�I1C@ l.�iCI:K 1'11CHA LV!4�L'll.l'�1 � Sect:ia� �: � � I+,��hlishment Survey Partirips�nts , _�......� ....._...., ....,,.�,. � Nzme: � �`' _.._.��....____.._.---.__.---.__.�.,��?�a�__.-_____..�...,.�., ____._�_______...--- , 1 ----- t.l�af F'��rch�.ger. �.7 h�., � T , , .----�----�---.. Acidress: • .__ �� �_._ • _.._._..........., A�e.�16�.17 _-------�---. __.. _........,�,,w..- - ------.....---...................._..._...___—__-- � ..�_ .._,..�m .�,�.,„�,,, S4x: ale Pem�le w...�. .�.......�.. 'Nt� �c of�dult Suriervisc>r . � ,, ��ty: G�� `�es ma�ve4-'r, 7�p�:,��: _��_r�..�..�.,....�._. - ��b �p�(!f'73 T'ime c,�fChcck:_.y.,�.r,.�.. _....._ prn C] pn� � .-.-.,_.__. �1�Fx:Uf F.stalsfishit�cnt: L� Ck�uin C�,���de�n�ent Ci Not Knawn I>bte af Che�k: �a� 4 � � - __......... _._.____-----------._..._....m.�,r.._,_ � T�y uftl�e Week:17 Mon Q"1'uc�s�Wec! CI'�Ctiuis C]F�i O Sat C7 Sun Style ofk:stabli�bment(Check Only Opej, ; ...- .._.... Canvenicncc Store 0 C3roce St�sre �. .Q E3ar ..�M._._�.M�......,...,._. _.,�..�. .,. , .. ..�.... ____.. , C] .C)c�s�i�nent St�re D 1_iqu�r�(�cx� C7 i�ri�ute C;[�t� VI�W�1 e�inn etc� ,.�...__.� - ..,......�..�.,.... - . . ... k7 E.TAs St�tine(�nl �� (�Pharn�aa,y/[���torc [�R�stt�,rrant � � [� Gqs Mitai-Mart � Cl(3ther�bawli��;�Nl�y,�olf club et�._ C]'1'abacx;unist _ Sect�on 2: ' r � � 'VVt�� �om lianc�. Check cqm ieted. '�'�s No O P P � 1J'Y'c.:s plecrscy r.c>�r[rnu�r.rn u�the rx,�ct quc:stron, i/'Nv�ecrsc<.4k1�.1!/tKS IPClICNt p�e[I�•o t�i scn�ion 3. �nw wa�tabacco marketed7 �. ()ver-ct�-c�u��tcr:youth asks tlie cterk for the pruduct. " ' ��� �(, C.� H`rotn a veodin,�machine�,a Ic�e:.icaut devii�. a o�t►��� r�g��: . s fx�CE, c.���-h .._........._._�..__.._._...___------__._.....��.._____...__. ` 7 c� ��.ct,c� Waa the P►�rr.hascr ankal fnr iD? Yes CI N Was thi��n [D-.�ticd chcck? Yes C.l �t�i Was the.Purrhs�s�er asked 6is/her age r Yes L7 Nc�i � Sex oft�lork: Ms�le L7 Femal�� A�proximate a�►e ofelcrlc: C'J"Tc�r+ ❑Yaun�;Adult�Rdult 0 Ulder Ade�ft Type uf tobacc��akett fvr: �) Ci�arettc�s l�r�nd af ci�aretteK�sked t'or:C] Murlt�aro t]New�ort Q()ther; � C:hcw(�)ip�Cigxrs 0 �;Ci�nrettr,s CJ t;hher ..___.__.__... lirand: ��G�,�,��.,�'� Was thC�rrc�cluct rc�quest� ti�vored (N()"�`Tobs�eeo a►r nne�t�c�l)? Yes I� No� �� M� rNx�s the aale rt��de?` Y�5'�No ❑ ',�, Tt""Yes"ht�w rnucb dic�the prc�ucC cost: $�°.�� Ws�a meei�t givcn?Yes E� Nn� � r �t'Ctl�4�= 1f t1�c yonth did pot en�tcr tbe�rrc�ad�ar did not attempt to pxrehAse tobs►eca prrKlucls please iedicate why: ❑ (htt uk�13tr5lnes5 I� T�m .!cm term cfosu�c: 0 tn u�irntian,cfc�si.�d at timt-ot'vi�.it C) lhivc thru�nl ❑ X:h�c.s��nt�It tc�bacco C� t)nlc�Csble T CI Utt�ttt�ko�CteSs CI "['ob�a:��out i�f ___..w..�.._._. .._.._--- stac;k CI ln;accr�siblc hv ouch ❑ W'holesale c�nlylcartons C7 Pres�nco ufpr,tice Cl t'errt�it Sus�ncied __„,..._.._ ....__ C[ 1'rivate club/pt:rsc�nal Cl Macbir►e braken �i�th inslz�''ta2r nn�• � CRher i-esidence O "fi�ca�,'t sell"but eobacce�:x.�rt in ."�`. _".�."�., s o.r• ��i� �rm i 4114115 ���