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0 SAN JOAQUIN COUNTY <br /> ?+ ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> .. �p• Telephone: (209) 468-3420 Fax: (209)464-0138 Web:www.slgov.org/ehd <br /> 'QCI FORM <br /> FOOD PROGRAM OFFICIAL INSPECTION REPORT <br /> Name of Facility: \ 1- � Date: -1—2— <br /> 2� <br /> Address: _2�a) l I \ City: Zip Code: C) S 3 <br /> Owner/Operator: Telephone: <br /> Program Element: \ (� Program Record: \\^ 1 `_ Inspection Type: <br /> B180 Posted ❑Yves ❑ Rermit Posted V ❑`Y`ess ❑I Re-Inspection on or After: <br /> 2 / <br /> prv_Q_V i <br /> � = tiemlCocationto _ .._,. _. item i Location <br /> Name: Hand Sink: of Chlorine: ppm Heat: oF= <br /> Exp.Date: arewashing Sink: of Quat.Amm.: ppm Other: of <br /> Received ByITitle: <br /> EH Speciali ✓ - Phone: <br /> ,-A,-A�j_ <br /> Time in: ^ Time Out: Pag!?of 2 <br /> EHD 16-24 (2n°pg) 4/3/13 FOOD PROGRAM OR CONTINUATION <br /> 16 <br />