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SAN JOAQUIN COUN . . <br /> _ z ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209) 468-3420 Fax: (209)464-0138 Web:www.slgov.org/ehd <br /> �/FORM <br /> FOOD PROGRAM OFFICIAL INSPECTION REPORT <br /> Name of Facility: C (1 U Si .' j(.' f.� II ` 4 Date: , 'Z /` <br /> Address: I �1 W, lj f G r n City' I r U Zip Code: <br /> Owner/Operator: Telephone: <br /> Program Element: Program Record: Inspection Type: A00 e, <br /> 6180 Posted ❑Yes ❑ Permit Posted G Yes ❑1 Re-Inspection on or After: <br /> OBSERVATIONS AND CORRECTIVE ACTIONS <br /> Pre- IQ ar c)<S 1 — <br /> mU S; n <br /> Name: Hand Sink: of Chlorine: ppm Heat: of <br /> '1 s <br /> .- { c <br /> Exp.Date: Narewashing Sink: of uat.Amm.: ppm Other: of <br /> Received By/Title: L <br /> EH Specialist: Phone: 4 7/ <br /> t-1- <br /> Time in: Time Out:11i'2 7 /f, y Pagee of <br /> EHD 16-24 (21°pg) 413,13 (i FOOD PROGRAM 0IR CONTINUATION <br />