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SAN .JOAQUIN COUP <br /> 4 ENVIRONMENTAL HEALTH DEPARTMENT <br /> - _ 1868 East Hazelto ue, o n, CA 95205-6232 <br /> c-0�iFoa�'�P Telephone:(209) 468-342 Fax:(209 $4-013 eb:www.sigov.org/ehd <br /> FOOD PROGRAM OFF PECTION REPORT <br /> Name of Facility: f Date: <br /> Address: /o City: Zip Code: <br /> Owner/Operator: Telephone: <br /> Program Element: Program Record: f� Inspection Type: <br /> SB180 Poste es No Permit Posted fes No l' Re-Inspection on or After: <br /> OB$ERVATIC?NS��ND G�RRECTIV�AGTaONS <br /> v. <br /> ....... —------- <br /> -.- :f> � <br /> o-, f <br /> ----------- - - .................. - <br /> _ ....... r. . - <br /> ,c y/cam �£'���.._..-----...._.._..............._...._......__..__` <br /> rature iNarewashm9 <br /> Name: Hand Sink: /0/ rof Chlorine�.,, pm Heat: <br /> -F <br /> Exp.Date: CI�o?7�/ arewashing Sink/ <br /> : �G j of Quat.Amm.: ppm Other: of <br /> Received By/Title <br /> EH Specialist: Phone: <br /> Time in: O.O Pae9of <br /> EHD 16-24 (2^^pg)4/3/13 FOOD PROGRAM OIR CONTINUATION <br />