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P41'" SAN JOAQUIN COUI <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> 1 .. :P• Telephone:(209) 468-3420 Fax:(209) 464-0138 Web:www.s'gov.orq/ehd <br /> '9��FORa <br /> FOOD PROGRAM OFFICIAL INSPECTION REPORT <br /> Name of Facility: V 1 Date: <br /> Address: City: Zip Code: <br /> Owner/Operator: elephone: <br /> 3 (�30f <br /> Program Element: a Program R cord: nsp ction Type: <br /> SB180 Posted Yes No L� Permit Posted Yes No Re-Inspection on or After- <br /> OBSERVATIONS AND CORRECTIVE ACTIONS <br /> u - <br /> `W /L MA4UNavo, � <br /> 3tAdy►I o <br /> N <br /> �lfn• <br /> Item/Location Tempera ire 0 Item/Location Temperature Item/Location Temperature <br /> ----- _ .._..._----- .......... ----- <br /> r1.ru.�^ �✓ - - <br /> L OaCIA <br /> WLFood Safety Certification Facility Hot Water Temperature Warewashing <br /> Name: - Hand Sink: L frfs,.�- o f Chlorine: ppm Heat: 'F <br /> Exp:Date: ho arewashing Sink:t!v OF <br /> uat.Amm.: ppm Other. o f <br /> Received By/Title: <br /> EH Specialist: Phone goof v 1, <br /> Time in: i Time utOCJ_1 V "3�" Page of <br /> l a <br /> EHD 16-24 (2"e pg) 4/9/12 FOOD PROGRAM OIR CONTINUATION <br />