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°Pam soy SAN JOAQUIN COur' <br /> a ENVIRONMENTAL HEALTH DEPARTMENT <br /> - _ 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209) 468-3420 Fax:(209) 464-0138 Web:www.sigov.orq/ehd <br /> �t FOR <br /> FOOD PROGRAM OFFICIAL INSPECTION REPORT <br /> Name of Facility: Date: !/ <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 /> OBSERVATIONS AND CORRECTIVE ACTIONS <br /> -------. .__... ............_...._....._......... <br /> . <br /> .............._..._.._......_.._...... ------ ---------- --- - ----..._ <br /> ................._......-- ----- _..._.....__ ..-.._---- _T.......-----— <br /> `pefatuCe - <br /> - <br /> Foacl"Sa#e Gerbfic;atton <br /> "W1 <br /> "11,6 - Fav =A VYaj+vashmg "_ <br /> i <br /> _. _. _ .__-. e.. ,.... . v,. <br /> Name: Hand Sink: of Chlorine: ppm Heat: `F <br /> Exp.Date: Warewashing Sink: 'F Quat.Amm.: ppm Other: 'F <br /> Received B Titl <br /> EH Specia'st: Phone( <br /> ime in: Time Out: Pag of <br /> EHD 16-24 (2nd pg) 4/3/13 FOOD PROGRAM OR CONTINUATION <br />