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SAN JOAQUIN COUN. Y <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209) 468-3420 Fax:(209) 464-0138 Web:www.s'gov.org/ehd <br /> ��FORN <br /> FOOD PROGRAM OFFICIAL INSPECTION REPORT <br /> Name of Facility: Date: <br /> Address: ,A City: Zip Code: <br /> Owner/Operator: Y l• 'Telephone: & •7 <br /> Program Element: Program Reco Inspection Type: <br /> SB180 Posted es No Permit Posted es !- No Re-Inspection on or After: <br /> OBSERVATIONS AND CORRECTIVE ACTIONS <br /> C. l� <br /> IC !, <br /> ttem/Location Temperature Item/Location Temperature Item 1 Location Temperature <br /> Food Safety Certification Facility Hot Water Temperature Warewashing <br /> _ _ ____ ...._.. ........- -- - --...- ------ <br /> Name: Hand Sink: 6, <br /> of Chlorine: m Heat: of <br /> Exp.Date: j arewashing Sink: <i` •. of Quat.Amm.: ppm Other: of <br /> Received By/Title: <br /> EH Specialist: Phoneme D j 44g. O2 <br /> Time in: 3 , Time Out: . o J Pag of, <br /> EHD 16-24 (2n1 pg) 4/9/12 FOOD PROGRAM OIR CONTINUATION <br />