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° c°"�" SAN JOAQUIN COUP <br /> za ENVIRONMENTAL HEALTH DEPARTMENT <br /> :'. 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209) 468-3420 Fax: (209) 464-0138 Web:www.s*gov.org/ehd <br /> ��FORN <br /> FOOD PROGRAM OFFICIAL INSPECTION REPORT <br /> Name of Facility: Date: <br /> Address: O / Ci!� Zip Code: <br /> i <br /> Owner/Operator: Telephone�y <br /> Program Element: Program Record: Inspection Type: ✓� <br /> i <br /> SB180 Posted Yes No Permit Posted Yes No Re-Inspection on or After: <br /> " OBSERVATIONS AND CORRECTIVE ACTIONS < a � � <br /> �i'PCc c Gf <br /> c / <br /> iP <br /> Item/Location Temperature Item l Location Temperature <br /> Food Safety Certification Facility Hot Water Temperature Warewashing <br /> Name: Hand Sink: of Chlorine: ppm Heat: of <br /> Exp.Date: Warewashing Sink: of Quat.Amm.: ppm Other: of <br /> Received By/Tit <br /> EH Special' Phone: .I. <br /> Time in: Time Otito` Page of <br /> EHD 16-24 (2nd pg) 4/3/13 FOOD PROGRAM OIR CONTINUATION <br />