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P4�1N SAN JOAQUIN COUN <br /> .c0 <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> • �q.••. Nip• Telephone:(209) 468-3420 Fax:(209)464-0138 Web:www.slgov.org/ehd <br /> ��FOR <br /> FOOD PROGRAM OFFICIAL INSPECTION REPORT <br /> Name of Facility: Q ,-e_ Date: Z :17—L3 <br /> Address: w /_ ` J /� City: Zip Code: 5j"s 2-C <br /> Owner/Operator: ho-'rt /T�2 j 4L—� Telephone: 4,72,c-)3154 <br /> Program Element: j d Program Record:""6-s <br /> Zy U Inspection Type: <br /> /0,,, <br /> SB180 Posted Yes No Permit Posted es Ci No Re-Inspection on or After: <br /> 2III MIN <br /> .. 4`_. � <br /> s <br /> Name: Hand Sink: of Chlorine: ppm Heat: of <br /> Exp.Date: ° rewashing Sink: of Ouat.Amm.: ppm Other: of <br /> Received By/Title: <br /> EH Specialist: / tri Phone: <br /> 1/6( _3 <br /> Time in: 2<_ Time Out: , 7__4:L> PagQof <br /> EHD 16-24 (2^d pg) 4/9/12 FOOD PROGRAM OIR CONTINUATION <br />