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：______