時間:      年     月     日    時    分至    時    分
地點:                                                     
執法機關:                                                  
當事人:                                                    
執法人員:                     執法證件號:                 
                                                  
記錄人:                                                    
現場情況:                                                  
                                                            
                                                            
                                                            
                                                            
                                                            
                                                            
                                                            
                                                            
當事人簽名或蓋章:             (見證人簽名或蓋章:        )
執法人員簽名或蓋章:
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