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SAN JOAQUIN C00Y <br /> %+ ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> • c .. a �P• Telephone:(209) 468-3420 Fax:(209) 464-0138 Web:www.slgov.orp/ehd <br /> '�C�FORt� <br /> FOOD PROGRAM OFFICIAL INSPECTION REPORT <br /> Name of Facility: d m Gt n'4zit h Date: <br /> Address: /630 .S O n City: , Zip Code: �O <br /> Owner/Operator: IVA Telephone: <br /> 9Y8-8 76a- <br /> Program Element: 27 Program Record: P13 D 5 2 7 0 / Inspection Type:A-4 <br /> �n <br /> SB180 Posted Yes ! No Permit Posted Yes No Re-inspection on or After: <br /> OBSERVATIONS AND CORRECTIVE ACTIONS <br /> r <br /> Item/Location Temperature Item/Location Temperature —Item/Location Temperature <br /> Food Safety Certification. Facility Hot Water Temperature Warewashing <br /> Name: Hand Sink: 'F Chlorine: ppm Heat: o f <br /> Exp.Date: arewashing Sink: of Ouat.Amm.: ppm Other: of <br /> Received By/Title: C M <br /> EH Specialist: a'6 Phone: 1363 <br /> _ r <br /> Time in: Time Out: �5 / Page of <br /> EHD 16-24 (2n1 pg) 4/9/12 FOOD PROGRAM OIR CONTINUATION <br />