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kwel <br /> SAN JOAOU1N GOur� <br /> ENVIRONMENT H DEPARTMENT <br /> 1868 East Haze Avenue, Stockton, A 95205-6232 <br /> o� y ..;a• <br /> Telephone:(209) 468-3 20 Fax:(209)464-0138 h:www.sigov.org/ehd <br /> �+eoRT' <br /> FOOD PROGRAM O A PEGTION REPORT <br /> Name of Facility: ©ate: <br /> Address: City: Zip Code: <br /> Owner/Operator: Telephone: <br /> Program Element: Program Record: Inspection Type <br /> SB180 Posted Yes No Permit Posted Yes No Re-Inspection on or After: <br /> PBS�RVAT.Ii��S,�4N1?CORE ECTIVE�C l`?V5 <br /> y Yw <br /> d � <br /> - - <br /> 7 .,. (tern�l.acat�nn .� _ `Tempeta#ure <br /> Ft>tsdSafety;Certrfi �z3n Facrl�ty�fot.WaterTem '.rature,, ,,; , -� �; Vl►�rewashing .' <br /> Name: - Hand Sink: °F Chlorine: ppm Heat: 'F <br /> Exp.Date: Warewashing Sink: of Ouat.Amm.: ppm Other: of <br /> Received By 1 Ti <br /> EH Special' Phone: <br /> Time in: Time Out: Pag of <br /> EHD 1fr24 12^d pg} 413(13 FOOD PROGRAM OR CONTINUATION <br />