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PUBLIC HEALTH SERVICES �oP .c,o <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DIVISION " ` ` <br /> Karen Furst, M.D., M.P.H., Health Officer •., P <br /> 304 East Weber Avenue, Third Floor • Stockton, CA 95202 <br /> 209/468-3420 <br /> FOOD FACILTIY IMPOUND NOTICE <br /> Firm Name & Address: L &A,/X.bv <br /> As authorized by the California Health and Safety Code, Division 104, Chapter 4, Article 4, the <br /> following action is being taken: <br /> Official Sample Receipt: The items listed below were olle ted as official samples on <br /> this date as authorized by Section 113925. Date a 01 <br /> Voluntary Condemnation and Destruction: I (We) hereby voluntarily agree to the <br /> condemnation and destruction of the following item(s) and release Publice Health <br /> Services and its agents from any and all liabilities regarding the agreed upon Voluntary <br /> Condemnation and Destruction. <br /> Method of Destruction <br /> Date <br /> Impound Notice: You are hereby notified that the following item(s) is/are impounded <br /> under the provisions of Section 113930. Date <br /> Impound Release: You are hereby notified that the following item(s) is/are released <br /> under the provisions of Section 113930. Date <br /> QUANITY UNITS ITEM DESCRIPTION LOCATION I.D.NO. RELEASED DATE <br /> AND INITIALS <br /> I11L* S M2 <br /> (12# S�-Q Mcw� _t 3 <br /> Authorized by: <br /> Registered Environ enta Healt ialist <br /> Acknowledged by: <br /> Firm R resentative <br /> JKFOOD.EH01 15 Division of San Joaquin County Health Care Serviccs <br />