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SAN JOAQUIN COUNtT' <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sagov.org/ehd <br /> 4�F0R� <br /> FOOD PROGRAM OFFICIAL INSPECTION REPORT <br /> Name of Facility: - r P S N, ?() V1 15 d ya } Date: ff j Q _/'j <br /> Address: l4 eq UJ City: 7r r Zip Code: 9 S 3 76 <br /> Owner/Operator: Telephone: F3s - /Cl 4/3 <br /> Program Element: Program Record: Inspection Type: CO +. n e <br /> SB180 Posted D Yes D No Permit Posted O Yes [] No Re-Inspection on or After: <br /> OBSERVATIONS AND CORRECTIVE ACTIONS <br /> I h e ! n i/ <br /> Coffe �� a <br /> tIC 0 per 40 Wd )S 11 C/ n /1 C x 4- 46, d--sOp"Asor <br /> gr42 r\dAer, 6C VITC4 <br /> I n I e <br /> Wdodhe 1 yes bac a, n -f 4o <br /> ry)U Q SMoe 41-, n = b l e S tar{ct re , CC 1 n c f- <br /> In 2 eK <br /> 4 Pro : d )0 C, le r 14Sn 2 eP YS' <br /> IC -® F C r u (- Ttw, 47-olOcr 14 1 <br /> - ov r tid 1' <br /> Name: e Ci I I C h�n Vndwnk: OG ; o f Chlorine: Heat: 'F <br /> Exp.Date: J I . 11 2shing Sink: .2 'F uat.Amm.: ppm ther: o f <br /> Received By/Title: <br /> EH Specialist: Phone: <br /> Time in: I 0: y U Time Out; `Y =Page.,:�f <br /> EHD 16-24(2-pg) 4/9/12 FOOD PROGRAM OIR CONTINUATION <br />