时间：_____年____月_____日____时_____分至_____时____分
地点：________________________________________________
处罚机关：____________________________________________
当事人：______________________________________________
现场检查（勘验）情况：
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
执法人员：____________ 执法证件号：____________
执法人员：____________ 执法证件号：____________
记 录 人：____________ 当事人签名或盖章：______
