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>°ice�dG SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> _ = 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> �4 • :P Telephone_ (209) 488-3420 Fax: (209) 404-0138 Web:www.sigov.org/ehd <br /> LFFORd <br /> FOOD PROGRAM OFFICIAL INSPECTION REPORT <br /> Name of Facility: 11 �. l 2 A J 1 M( I Date: <br /> ddress: Oct C' yam` City: (��1_ �( Zip Code: cl <br /> '4 <br /> Owner/Operator: t�j 1 C— Telephone: <br /> Program Element: { Program Record: Co 0c f (PC-) Inspection Type:C(j)_A ��,�+ <br /> SB180 Posted 11 Yes ❑ Rermit Posted El Yes ❑I Re-Inspection on or After: <br /> - <br /> E§SERVATJ0,N ANt3 CC3R EcTNE AcT(ONS <br /> C(SN1 lC�tl��- S'rG1-ISS : [�,� �-�- C,�}-►[�-Pfi S G�1 G�i`iC.'�P� b_ <br /> SGIW CA ��u [/(-oW itZ CM C'�6 CX-G�A1 .P_U , S • cAb L2 <br /> co"n1CI-In�� <br /> V cl "no-Ili- 's'ee; CIVN �-aw Gk�A --; bt�u5 <br /> ()I - yU- C ct <br /> i <br /> 77 <br /> CUN�`t1�11Cd� - RC1` =� <br /> Item/Location Temperdw fe Rein!Location Temperature <br /> Food Safely Certification, Facility.blot Water Temperature Warewashing <br /> Name: Hand Sink: aF Chlorine: ppm Heat: 'F <br /> Exp. Date: _arewashing Sink: `F Quat.Amm.: ppm Other: 'F <br /> Received By!Title: ` S� Lary/VG J <br /> EH Specialist: Phone: 97LQ ?AA <br /> ime in: — -- Time Out: y � Page of f <br /> EHD 15-24 (2nd pg) 4013 1 FOOD PROGRAM 0!R CONTINUATION <br />