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04"'" c SAN .10AQUIN <br /> COU '`Y <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.segov.org/ehd <br /> gt�FORa <br /> FOOD PROGRAM OFFICIAL INSPECTION REPORT <br /> Name of Facility: 1W Volf`2i Date: Z <br /> Address: 7��7 �iZ�grn City: Zip Code: <br /> Owner/Operator: �( P grj /� /y-/uL Telephone: <br /> Program Element: J Program Record: �1 + Inspection Type: <br /> SB180 Posted Yes a No Permit Posted Yes ! No l Re-Inspection on or After: <br /> Y i/1, /Xj III nAlilt�_- h '4_'1 <br /> it G� <br /> ,�c�• s <br /> f A (/ z_a -o1nivya v( <br /> u IIA <br /> F C '' v► v <br /> Name: �/� 1 G ✓ti/ nd Sink: !I o f Chlorine: ppm Heat: o f <br /> Exp.Date: I Y ' I arewashing Sink: V 'F Quat.Amm.: ppm Other: 'F <br /> Received By/Title. <br /> EH Specialist: , Phone: f <br /> Time in: 1 i Time Out: Pagrzry of� <br /> EHD 16-24 (2nd pg) 4/3/13 FOOD PROGRAM OIR CONTINUATION <br />