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SAN JOAQUIN COUA <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> • c .. �p• Telephone:(209) 468-3420 Fax:(209) 464-0138 Web:www.sigov.org/ehd <br /> 4LI FORK <br /> FOOD PROGRAM OFFICIAL INSPECTION REPORT <br /> Name of Facility: Date: (1/-J+/?A <br /> Address: 35 City: mm for, <br /> Zip Code: 15-u-5- <br /> Owner/Operator: 1�:. d Telephone: <br /> u <br /> Program Element: Program Record: �1 ,.^ Inspection Type: aot <br /> SB180 Posted Yes o Permit Posted eye No Re-Inspection on or After: <br /> OBSERVATIONS AND CORRECTIVE ACTIONS <br /> � nM� 5 a� �a� S�u'Z� rr -�luci• ���- �vclav� -�- S�Lvz2 �// _ �i�...- <br /> d - <br /> 20 °1 oa�z tuS a <br /> Item/Location Temperature Item/Location Temperature <br /> Food Safety Certification Facility Hot Water Temperature Warewashing <br /> Name: Hand Sink: °F Chlorine: Ppm Heat: 'F <br /> Exp.Date: Warewashing Sink: 'F Quat.Amm.: ppm Other: 'F <br /> Received By/Title: <br /> EH Specialist: Phone: <br /> Time in: Time Out: (r': A Page of <br /> EHD 16-24 (2n1 pg) 4/3/13 1 V FOOD PROGRAM OIR CONTINUATION <br />