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oPa"'" SAN JOAQUIN COUN i f <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209)468-3420 Fax: (209)464-0138 Web:wwW.s4gov.org/ehd <br /> A��FOfR� <br /> FOOD PROGRAM OFFICIAL INSPECTION REPORT <br /> Name of Facility: / fDate: l jJ r0 �� <br /> Address: /5- jr t.-`. L-A--LL-A--LCity: G� Zip Code: <br /> Owner/Operator: a v. y �' Telephone: ,.. <br /> Program Element: �Z Program Record: co Inspection Type: llyke4 <br /> SB180 Posted ❑Yes ❑ No Permit Posted 'u Yves(/❑ No Re-Inspection on or After: <br /> OBSERVATIONS AND CORRECTIVE ACTIONS <br /> h-t �n Ulf <br /> h rt ham Nj V140 n bowl <br /> ,q ac-r�i5 Cc ' i df v <br /> lAfAV W&PI vcd� til - <br /> 1 �- YA itWoit <br /> ho tile <br /> /d <br /> div" C4 I <br /> roc/ <br /> Item/Location Temperature Item/Location Temperature Item I Location Temperature <br /> Food Safety Certification Facility Hot Water;Temperature Warewashing <br /> Name: Hand Sink: of Chlorine: ppm Heat: of <br /> Exp.Date: arewashing Sink: of Quat.Amm.: ppm Other: °F <br /> Received By/Title: <br /> EH Specialist: \ Phone: <br /> Time in: l S v Time Out: c. (V Page'of <br /> EHD 16-24 (2otl P9) 4/9/12 FOOD PROGRAM OIR CONTINUATION <br />