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SAN JOAOUIN COL_ fY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> J. 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209) 468-3420 Fax:(209) 464-0138 Web:www.siclov.orq/ehd <br /> L�FOR� <br /> FOOD PROGRAM OFFICIAL INSPECTION REPORT <br /> Name of Facility: � Date: <br /> Address: .a r7 d City: Zip Code: �a <br /> Owner/Operator: n Telephone: a 9 <br /> _DO <br /> Program Element: I Program Record: R O cJV-zo c) Inspection Type: �n <br /> B180 Posted Aes No Permit Posted Yes No Re-Inspection on or After: <br /> 3 ., V:g, <br /> l -fYoo rn ( r-t�v�c L 1 -1 r cfu ct i co-b (e- <br /> o A- CA n Y1 <br /> t . r� S v <br /> ri Yi C l <br /> L, h o Y,e- n o <br /> ­e�r r oc.r`r <br /> Y r b <br /> 12 Q n - n a- n <br /> trire <br /> . -fm y <br /> Il u) o <br /> Name: Hand Sink: of Chlorine: ppm Heat: of <br /> Exp.Date: Warewashing Sink: of Ouat.Amm.: ppm O )20 of <br /> Received By/Title: ?` Q <br /> EH Specialist: v Phone: <br /> A� aI " 17 <br /> Time in: Time Out: t ; 'jJo Page 'if -a- <br /> EHD 16-24 (2nd pg) 4/9/12 1 FOOD PROGRAM OIR CONTINUATION <br />