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SAN JOAQUIN COUN—W <br /> q. ENVIRONMENTAL HEALTH DEPARTMENT <br /> _ 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209) 468-3420 Fax:(209)464-0138 Web:www.sigov.org/ehd <br /> <<FOM <br /> FOOD PROGRAM OFFICIAL INSPECTION REPORT <br /> Date: /_/G -l S <br /> Name of Facility: <br /> Address: City: T o � Zip Code: (�5 j 1 <br /> 2439 !va r <br /> Telephone: <br /> Owner/Operator: <br /> Program Element: Program Record: Inspection Type: �� I <br /> SB780 Posted Yes No Permit Posted Yes No Re-Inspection on or After: <br /> ....,,,,, s - .,..a <br /> et �CJ�_ .._ <br /> } �dato wl 3 Gcmn is 1/ darn }urs---- <br /> 1 Wa } tr of -- Ccr ecJ in l WeeA <br /> ___ Prov' �C � an ' l� Ltr �tSL S #.;n in I LtlLOrl. <br /> S G h N a rolS 6CK i h rr <br /> � h <br /> Olt 3 W erlC <br /> en / pn liA iAC:n rC i "C iv± <br /> I ; Itn ; l �u rtvt �' uS 'fcrslar Ccn� u l :o <br /> C rec 1 <br /> uv9 4e, i IPS }t-ooI <br /> Ire- a 1 /00- lOX•F. Cc r ck foda <br /> SQr1i4 o uq ; <br /> TY�f l' ylj ._. Soyr S F <br /> WeIZ. :n qI ! r .4e - rl` Ll r <br /> a"� 3 .,i4.. rlstiing. <br /> Food Safety Certification <br /> Name: vl Y 1C;/ 1 " ,1 i Hand Sink: OVk of hlorine: PPM eat:... OF <br /> Exp.Date: a , c/. / a/ arewashing Sink: of uat.Amm.: PPM ther: of <br /> Received By/Title: <br /> 1 777 <br /> EH Specialist: Phone: <br /> Time in: �. O Time Out: /; PegeZt <br /> EHD 1624 (2m pg) 4013 FOOD PROGRAM OIR CONTINUATION <br />