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°"'" SAN JOAQUIN COUNTY <br /> z+ ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> • .: P• Telephone: (209) 468-3420 Fax: (209) 464-0138 Web:www.s4gov.org/ehd <br /> 4<<FOR� <br /> FOOD PROGRAM OFFICIAL INSPECTION REPORT <br /> Name of Facility: I Date: <br /> Address: City: Zip Code: r, <br /> Owner/Operator: v VTelephone: <br /> Program Element: Program Record: Inspection Type: <br /> SB180 Posted L <br /> es o Permit Posted ❑Yes ❑No Re-Inspection on or After: <br /> O13SERVAT10'NS e Q CORRECTIVE ACTIONS <br /> sId 6"S <br /> _. <br /> IV <br /> a t <br /> !V(77 <br /> Name: and Sink: of Chlorine: ppm Heat: of <br /> Exp.Date: /� arewashing Sink: of Quat.Amm.: ppm Other: of <br /> Received By/Title: <br /> EH Specialist: Phone: <br /> Time in: o Time Out: (©�?JQ Page of <br /> EHD 16-24 (20°pg) 413113 FOOD PROGRAM OIR CONTINUATION <br />