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°411y SAN JOAQUIN COUi <br /> 'o. .coG <br /> 0:1 XX ENVIRONMENTAL HEALTH DEPARTMENT <br /> = 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209) 468-3420 Fax:(209) 464-0138 Web:www.sigov.org/ehd <br /> <<POR <br /> FOOD PROGRAM OFFICIAL INSPECTION REPORT <br /> Name of Facility: L C / Date: <br /> Address: 1Z s• S �� ` �c City: Zip Code: '7' 51 <br /> Owner/Operator: r U e^: Telephone: <br /> Program Element: D 0 Program Record: / C, 3 fi`G Inspection Type: <br /> SB180 Posted Yes No Permit Posted Yes No Re-Inspection on or After: <br /> -4Sc )li,. 4GcG G,r o S Gini cc .ff <br /> O <br /> Lt �S; dc o � ah but;l;4 <br /> t U C Gr-� Ci me G - i n S pec 4;ori <br /> 44e4c,4ej S h I r CQ r a a Ver <br /> U)ee 4012 hs j ar4rhce4/y rG c; 1; 4 <br /> C4 4 Q f'-f h <br /> Ci I (� sa b ym 1,.5 Q c u r i <br /> i GI f 4 r re r eAeltis C � CI <br /> CG <br /> Item/Location Temperature Item/Location Temperature <br /> Food Safety Certification Facility Hot water Temperature Warewashing <br /> Name: Ha 'd Sink: of Chlorine: ppm Heat: of <br /> Exp.Date: arewashing Sink: of Quat.Amm.: ppm Other: of <br /> Received By/Title: <br /> EH Specialist: - Phone: 3/ <br /> Time in: -lO Time Out: �n �S Page/ of <br /> EHD 16-24 (2n1 pg) 4/3/13 V oC FOOD PROGRAM OIR CONTINUATION <br />