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°,oma SAN JOAQUIN COUP <br /> ' ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> q� FoaN:" <br /> Telephone:(209) 468-3420 Fax:(209) 464-0138 Web:www.Siaov.org/ehd <br /> FOOD PROGRAM OFFICIAL INSPECTION REPORT <br /> Name of Facility: <br /> Date: <br /> ddress: <br /> City Zip Code: <br /> wner/Operator: Telephone: <br /> Program Element: / Program Record: Inspection Type: <br /> BISO Posted Yes No Permit Posted Yes No Re-Inspection on or After• _ <br /> P <br /> •55' <br /> c <br /> ,—IWR.R.W,FFood Safety Certification Facility Hot Water Temperature Warewashing <br /> Name. Hand Sink: `F Chlorine: ppm Heat: 'F <br /> Exp.Date: are hing Sink: -F Ouat.Amm.: ppm Other: 'F <br /> Received By/Ti <br /> H Special! Phone• <br /> !me in: �O•a� TimeOut: <br /> EHD 16-24 (2-pg) 4/3113 FOOD PROGRAM OIR CONTINUATION <br />