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SAN JOAQUIN COUN'► <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> • c... �P• Telephone:(209) 468-3420 Fax:(209) 464-0138 Web:www.slgov.org/ehd <br /> FOOD PROGRAM OFFICIAL INSPECTION REPORT <br /> Name of Facility: LDate: <br /> Address: I 1 - J I. City: '(rn rCIA G� Zip Code: 9S-7 <br /> y <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 /> n <br /> r1 d� a Pr �O 8l S S S J'- Ic <br /> r v 0( a Nu r <br /> .J Gn <br /> Item/Location Temperature Item!Location Temperature Item/location Temperature <br /> Food Safety Certification Facility Hot Water Temperature Warewashing <br /> Name: Hand Sink: of Chlorine: ppm Heat: of <br /> Exp.Date: arewashing Sink: of r <br /> uat.Amm.: ppm Other: of <br /> Received By/Title: p <br /> EH Specialist: P ne: <br /> Time in: Time Out: 7 0 Page of IV <br /> EHD 16-24 (2nd pg) 4/9/12 FOOD PROGRAM OIR CONTINUATION <br />