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>4RA �ti SAN JOAQUIN COUNT <br /> .z� ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> �*tlsati�Y' Telephone:(209)468-3420 Fax:(209) 464-0138 Web:www.siaov.orD/ehd <br /> FOOD PROGRAM OFFICIAL INSPECTION REPORT <br /> Name of Facility: Date: <br /> ddress: 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 /> OBSERVATIONS AND CORRECTIVE ACTIONS <br /> i .fT n G7/ i Vic+-rx/✓ <br /> T� <br /> c <br /> ilk E <br /> ! -i r <br /> ------- -- = <br /> Item/Locetion Temperature Item/Location Temperature <br /> 0. o _ <br /> Food Safety Certification F Facility Hot Water Temperature Warewashing <br /> erre: Hand Sink: -.F Chlorine: ppm Heat: "F <br /> Exp.Date: Warewashing Sink: ..F Ouat.Amm.: PPM Other: 'F <br /> Received By/Titl <br /> EH Specialist: 1O, Phone: <br /> Time In: ITime Out: Pag3of <br /> EHD 16-24 (2n°pg) 4/3113 FOOD PROGRAM OR CONTINUATION <br />