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,Opa I SAN JOAQUIN COU Y <br /> 4 2� ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> �4...• �;;P Telephone:(209) 468-3420 Fax:(209)464-0138 Web:www.si4ov.or /q ehd <br /> <<FOR <br /> FOOD PROGRAM OFFICIAL INSPECTION REPORT <br /> Name of Facility: `Y- Date: <br /> 7 s <br /> Address: S City: Zip Code: <br /> Owner/Operator: I /� Lry /f Telephone: <br /> Program Element: /„/, Prograrm R cord: ,rt p Inspection Type: <br /> SB180 Poste Yes No Permit Poste Yes No o Re-Inspection on or After: <br /> OBSERVATIONS AND CORRECTIVE ACTIONS <br /> ltenVLocation Temperature Item L Location Temperature <br /> �. .. _ <br /> yz <br /> DI's <br /> Food Safety Certification _ - Facility Hot Water.Temperature <br /> w 111f rewashm ,�� ' <br /> Name: ���+ Hand Sink: ofChlorine: ppm Heat: aF <br /> Exp.Date: / arewashing Sink: of Quat.Amm.: ppm Other: of <br /> 1e9D <br /> Received By/Title: NM <br /> EH Specialist: 1 13 Phone: <br /> Time in: I Time Out: PageZbf� <br /> EHD 16.24 (2n°pg)4013 FOOD PROGRAM OIR CONTINUATION <br />