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SAN JOAQUIN COU. <br /> •.OG <br /> Z� ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209) 468-3420 Fax: (209)464-0138 Web:www.smgov.org/ehd <br /> �iFORa <br /> FOOD PROGRAM OFFICIAL INSPECTION REPORT �arto5 <br /> Name of Facility: I r - Date: <br /> Address: -, 2 -PiPacic -V- City: t _ n zip Code:l ;L0 <br /> Owner/Operator: Wo <br /> Q r TU Telephone: --WO 0 <br /> Program Element: 25 Program Record: 10A 01 <br /> ` 70141 <br /> Inspection Type: <br /> B180 Posted es ❑ Rermit Posted Y Yes ❑ 1 Re-Inspection on or After: <br /> :r <br /> qo4 worK-t r mi ce <br /> iA <br /> F qty Water trertt�r " <br /> Name: a `nom Hand Sink: of Chlorine: ppm Heat: of <br /> Exp.Date: Warewashing Sink: of Quat.Amm.: ppm Other: of <br /> Received By/Title: <br /> EH Specialist: / _ Phone: <br /> Time in: 1 Time Out: f / ' Page Lof <br /> EHD 16-24 (2^'pg) 4/3/13 ! 6 FOOD PROGRAM 0IR CONTINUATION <br />