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SAN JOAQUIN COU& <br /> N: X <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.sigov.org/ehd <br /> ��FOR <br /> FOOD PROGRAM OFFICIAL INSPECTION REPORT <br /> Name of Facility: ( i Date: !" / <br /> CA nl L( r r _ <br /> Address: 1 1 1 f J�^ S City: I r��c Zip Code: 3 LC <br /> Owner/Operator: w Telephone: <br /> Program Element: Program Record: Inspection Type: <br /> SB180 Posted Yes ❑ No Permit Posted Yes L No Re-Inspection on or After: <br /> :► od d. ruo C4 4�- <br /> I' <br /> 1 <br /> CM Cie,. on /1 <br /> OctOr 0 Re J)POI 11 :0104 iO4 <br /> Item/Location Temperature Item/Location Temperature <br /> o UC li 'S �(a ( lou �5 �. � iV-U it' J� cd�0ii:' � r- <br /> �G <br /> Food Safety Certification Facility Hot Water Temperature Warewashing <br /> h - ----- ----- <br /> Name: Hand Sink: f;� of chlorine: ppm Heat: of <br /> t' <br /> Exp.Date: s 3 Warewashing Sink: of Quat.Amm.: ppm Other: of <br /> Received By/Title: �✓'y <br /> EH Specialist: Phone: 44r. 31/ <br /> Time in: ! Time Out: ` �// Page.. of <br /> EHD 16-24 (2^a pg) 4/3/13 FOOD PROGRAM OIR CONTINUATION <br />