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"W" SAN JOAQUIN COU* <br /> Za ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> c4.• ;o Telephone:(209) 468-3420 Fax: (209) 464-0138 Web:www.sagov.org/ehd <br /> �/PORN <br /> FOOD PROGRAM OFFICIAL INSPECTION REPORT <br /> Name of Facility: S / Date: <br /> Address: c eh City: Zip Code: <br /> ,t 4 �S3S6 <br /> Owner/Operator: Telephone: <br /> Program Element: Program Record: Inspection Type: <br /> SB180 Posted i es No Permit Posted _ es No Re-Inspection on or After: <br /> OBSERVATIONS AND CORRECTIVE ACTIONS <br /> 61 Or&j1j d Nrn S 1, r Soap r - Cc ctfl Sci/a <br /> C re t �od� <br /> 2 jc -u <br /> I �Cfn of 3 d Ch'An 11 .14 <br /> Item/Location Temperature Item/Location Temperature <br /> - _ -- — — - .........-- <br /> u <br /> Food Safety Certification Facility Hot Water Temperature Warewashing <br /> Name: w Hand Sink: U< 'F Chlorine: ppm �Het: `F <br /> jk r.Exp. Date: arewashing Sink: 'F Ouat.Amm.: ppmer: "F <br /> Received By/Title: <br /> If V <br /> EH Specialist: Phone: <br /> Time in: Time Out: l 3 D t Page of <br /> EHD 16-24 (2n°pg) 4/3/13 FOOD PROGRAM OIR CONTINUATION <br />