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ot,AS+.IM..F <br /> AN .IOAQUIN COUN..i <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209) 468-3420 Fax:(209) 464-0138 Web:www.s6goy.org/ehd <br /> Gt Fb'R <br /> FOOD PROGRAM OFFICIAL INSPECTION REPORT <br /> Name of Facility: 'r Date: <br /> Address: ; 1 , -i i ) r r, City: -- Zip Code: t' <br /> Owner/Operator: Telephone: <br /> Program Element: Program Record: Inspection Type: <br /> va 4• n ' <br /> B180 Posted D Yes No Permit Posted ❑Yes ONO Re-Inspection on or After: <br /> V (AVS I a S. U .i <br /> 47� <br /> ), V1 - 4, 1e in G fe pop rd to Vilif / <br /> A-J Z r- OU /o'I Chlp/ , ,e <br /> door S p�+»1 4a b le <br /> S0111311 bar /'/— Lt7t,i><- ;'N y / <br /> Name: land Sink: to V 4 ^F hlonne: ppm eat: -F <br /> N C <br /> Exp. Date: arewashing Sink: fay "F uat,Amm.: ppm ther: `F <br /> Received By/Title: r / <br /> z: <br /> EH Specialist: Phone: <br /> Time in: t, , Time Out: f� Page of <br /> EHD 1624 (2W pg) 4x12 FOOD PROGRAM OR CONTINUATION <br />