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oP41'" SAN JOAQUIN COL Y <br /> � ' .CSG <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 /> 4�i FORN <br /> FOOD PROGRAM OFFICIAL INSPECTION REPORT BY-( <br /> Name of Facility: Q�ry?_ Date: /-30-/L/_ 0_/L/ <br /> Address: 30/0 &.0 City: Zip Code: 153 D <br /> Owner/Operator: c-•1' Telephone: <br /> 83G- 57 <br /> Program Element: lep /A Program Record: O D 2 Inspection Type: <br /> SB180 Posted D(Yes No Permit Posted Yes No Re-Inspection on or After: �WO <br /> OBSERVATIONS AND CORRECTIVE ACTIONS <br /> r a ka 17 CIS i C Y L -- GclQ r»n O v2 r -- <br /> 0-10 " -3/-/ <br /> ag--f i s Ur, �e raoa vn , r- <br /> =icevl u-r, . c ra`� <br /> -E <br /> 'n Ixe <br /> 0- r 1p+-J J+-es o -71 <br /> Vp CCL a-5 fr'1 zt <br /> f <br /> Item/Location Temperature Item/Location Temperature <br /> Gt�C.r'L S rs it J j1Y f 32 <br /> n "` <br /> a <br /> Food Safety Certification Facility Hot Water Temperature Warewashing iS yrs ,L <br /> Name: y aw n Hand Sink: of Chlorine: ppm at lav of <br /> Exp.Date: _ _ G Mush! Sink: l of Quat.A6m.: �� ppm Other: . � <br /> Received By/Title: J V <br /> EH Specialist: �_ -t� Phone: <br /> Time in: Time Out: Pageaff <br /> EHD 16-24 (2"d pg) 4W3 FOOD PROGRAM OIR CONTINUATION <br />