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"g`'!" SAN JOAQUIN COL i'Y <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209) 468-3420 Fax:(209) 464-0138 Web:www.sagov.org/ehd <br /> ��FORN <br /> FOOD PROGRAM OFFICIAL INSPECTION REPORT <br /> Name of Facility: Date: <br /> Address: ` v t , City: /,� ` Zip Code: 95 3 74 <br /> Owner/Operator: Telephone: <br /> � 3( y �by <br /> Program Element: Program Record: Inspection Type: G All <br /> SB180 Posted Yes No Permit Posted ,-Yes No Re-Inspection on or After: <br /> -F- . <br /> 10 <br /> ae, I ne �10 c Onder Shc I ieG U.Cle, <br /> ) <br /> o IIa 10 Ip a "15 S; _S h 1 � le, /G �. <br /> Cil i Y) A, /� n c.f W cA 4 e,- r.4 f G byvt C <br /> a dI <br /> d " r G ; <br /> Cit <br /> �o doI act <br /> ItemJLaca i_ om� perature: Item l Location <br /> l J fu Ic V 7` <br /> W q flev- <br /> Name: C he , Hand Sink: O of =h - ppm Heat: �� Z °F <br /> Exp.Date: / arewashing Sink: /G of ppm Other:- of <br /> Received By/Title: <br /> EH Specialist: Phone: / (i. / <br /> Time in: ' 'LJ� Time Out: Z r1/33 Page of 2 <br /> EHD 16-24 (2n1 pg) 4/3/13 // FOOD PROGRAM OIR CONTINUATION <br />