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�a�4 .coG SAN JOAQUIN COUt4fY <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.sipov.or /q ehd <br /> FOOD PROGRAM OFFICIAL INSPECTION REPORT <br /> Name of Facility: / Date: /2 2 <br /> Address: !/(J ✓ Yn Y� City: 4`�/, Zip Code: <br /> c t i v"c <br /> Owner/Operator: i �. Telephone: <br /> Program Element: lwp Program Record: Inspection <br /> SB180 Posted Yes No Permit Posted Yes No Re-Inspection on or After: <br /> a OBSERVATIONS AND CORRECTIVE ACTIONS <br /> aPrlJ - -- - <br /> A -- <br /> •c�,�/ r/Grim kr f c U_it Vit - 167 <br /> 06 0 <br /> L vl,ki C/ 2 ? air1,41, A+ 3'o am <br /> fit', q vtv <br /> W <br /> 44':�Yctk o' <br /> JP/ <br /> . ,- o' o <br /> --- ap D ta,n•l,% -_LVL--u1J -t jo, - YvL <br /> Item/Locationj.Temperature Item/Location Temperature <br /> Food Safety Certifcation Facility Hot Water Temperature Warewashing <br /> Name: Hand Sink: of 'Fuat. <br /> hlorine: ppm Heat: of <br /> Exp.Date: Yarewashing Sink: °F Amm.: ppIr 'Other. of <br /> Received By/Title: <br /> EH Specialist: Phone: <br /> Time in: Z Time Out: Page o <br /> EHD 16-24 (2"pg) 4/3113 FOOD PROGRAM OIR CONTINUATION <br />