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4"'" SAN JOAQUIN CiOUn <br /> �o c�G <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> __- 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209) 468-3420 Fax: (209) 464-0138 Web:www.sjgov.org/ehd <br /> FOOD PROGRAM OFFICIAL INSPECTION REPORT <br /> Name of Facility: Date: <br /> Address: U - �J'kCity: Zip Code: Za�- <br /> Owner/Operator: `vIJ Telephone: <br /> Program Element: Program Record: Inspection Type: <br /> SB180 Posteda No Permit Posted e 1 No Re-Inspection on or After: <br /> OBSERVATIONS AND CORRECTIVE ACTIONS <br /> Ls <br /> aP- c# <br /> ItemfL.ocation Temperature Item t Location Temperature <br /> ------- --- ------ — <br /> Food Safety Certification Facility Hot Water Temperature Warewashing <br /> Name: Hand Sink: �F Chlorine: ppm Heat: 'F <br /> Exp.Dat Warewashing Sink: �F Ouat.Amm.: ppm Other: °F <br /> i <br /> Received By/Title. <br /> EH Specialist: Phone: <br /> Time in: Time Out: (, Page of <br /> EHD 16-24 (21d pg) 4/3/13 FOOD PROGRAM OIR CONTINUATION <br />