Beverage Dispensing Sanitation Report Form
Use this form to document sanitation checks, cleaning activities, inspection findings, corrective actions, and sign-off for beverage dispensing equipment.
Sanitation Report Details
Report Date
*
-
Month
-
Day
Year
Date
Report Time
*
Hour Minutes
AM
PM
AM/PM Option
Facility / Location Name
*
Beverage Dispensing Equipment Name or ID
*
Equipment Type
*
Please Select
Soda Fountain
Coffee Machine
Tea Dispenser
Juice Dispenser
Water Dispenser
Beer Tap System
Slush Machine
Other
Report Submitted By
*
First Name
Middle Name
Last Name
Cleaning and Sanitization Log
Cleaning and Sanitization Date
*
-
Month
-
Day
Year
Date
Cleaning and Sanitization Time
*
Hour Minutes
AM
PM
AM/PM Option
Cleaning Method or Procedure Used
*
Please Select
Manual wash and rinse
CIP cycle
Foam cleaning
Spray-and-wipe
Steam sanitization
Three-compartment sink method
Other
Sanitizer or Cleaner Product Name
*
Concentration or Dilution Used
Contact Time
Were all required steps completed?
*
Yes
No
Inspection Findings
Dispensing Surfaces
*
Compliant
Needs Attention
Not Compliant
Nozzles / Taps
*
Compliant
Needs Attention
Not Compliant
Drip Trays
*
Compliant
Needs Attention
Not Compliant
Lines / Tubing
*
Compliant
Needs Attention
Not Compliant
Surrounding Area
*
Compliant
Needs Attention
Not Compliant
Observed Issues
Visible residue
Unusual odor
Mold present
Leaks observed
Contamination observed
Other
Inspection Notes
Corrective Actions and Follow-Up
Corrective Action Taken
*
Parts Replaced or Serviced
Re-cleaning Required?
*
Yes
No
Next Scheduled Sanitation or Inspection Date
-
Month
-
Day
Year
Date
Final Equipment Status
*
Please Select
Approved for Use
Approved with Follow-Up
Out of Service
Attestation and Sign-Off
Inspector Name
*
First Name
Middle Name
Last Name
Inspector Signature
*
Supervisor/Reviewer Name
First Name
Middle Name
Last Name
Submit Report
Submit Report
Should be Empty: