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,oP .�oG SAN JOAQUIN COI' Y <br /> Q` z+ ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> c4.. iP Telephone: (209) 468-3420 Fax: (209) 464-0138 Web:www.sigov.orQ/ehd <br /> LI FORM <br /> FOOD PROGRAM OFFICIAL INSPECTION REPORT <br /> Name of Facility: MCI rs�-1au S Date: -2-,YJ_ 1 L4 <br /> Address: �'aO y-CA yl(3 npL� `� v d City: `7 L +O C_K-t7Dn <br /> �/a, Zip Code: <br /> Owner/Operator: 5) Telephone: 0 <br /> 15';L_17o 1?0 <br /> Program Element: (n20 Program Record: P R_c-) 505 13p.-L Inspection Type: `Z0 v.-h 1721? <br /> Posted - Yes No Permit Posted )(Yes No Re-Inspection on or After: �` ``�� <br /> OBSERVATIONS AND CORRECTIVE ACTIONS <br /> Yl <br /> ttem/Location j Temperature Item/Location Temperature <br /> Food Safety Certification Facility Hot water Temperature Warewashing <br /> .y........-...__....--.._...........--......... _ <br /> _..:.__... —— ---- --... <br /> Name: H Sink: - <br /> of Chlorine: ppm Heat: of <br /> Exp.Date: g Sink: /c2/ of Quat.Amm.: ppm Other: of <br /> Received By/Title: <br /> EH Specialist: 42 Phone: <br /> Time in: I 1 .0 O Time Out: I Pagel f � <br /> EHD 16-24 (2M pg) 4/3/13 l FOOD PROGRAM OIR CONTINUATION <br />