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SAN JOAQUIN COUN _ <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.si-gov.org/ehd <br /> ��FOR <br /> FOOD PROGRAM OFFICIAL INSPECTION REPORT <br /> Name of Facility: L 1 Date: ' <br /> Address: ''] �v r s 1 h f„ City: � �� Zip Code: I. <br /> 1 W � S� Gv <br /> Owner/Operator: j Telephone: <br /> Program Element: Program Record: Inspection Type: <br /> SB180 Posted Yes No Permit Posted Yes No Re-Inspection on or After: <br /> OBSERVATIONS AND CORRECTIVE ACTIONS <br /> U) W <br /> c IA u5t Cufrv„vil a} <br /> Item/Location Temperature Item/Location Temperature Item/Location Temperature <br /> - _�.---- .__..._..__.. <br /> Safety Certification Facility Hot water Temperature Warewashing <br /> Name: Hand Sink: of Chlorine: ppm Heat: of <br /> Exp. Date: Warewashing Sink: of Ouat.Amm.: ppm Other: of <br /> Received By/Title: <br /> EH Specialist: Phone: <br /> Time in: Time Out: Page of 3 <br /> EHD 16-24 (2nd pg) 4/9/12 FOOD PROGRAM OIR CONTINUATION <br />