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SAN JOAQUIN COUP <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.s6- ov.orq/ehd <br /> 4��FORa <br /> FOOD PROGRAM OFFICIAL INSPECTION REPORT <br /> Name of Facility: t W S Date: <br /> Address: / City: Zip Code: <br /> Owner/Operator: I <br /> //�� Telephone: <br /> Program Element: 6 / Program Record: Af 53 s /1S Inspection Type: -YL� <br /> SB180 Posted Yes No Permit Posted es - No J Re-Inspection on or After: <br /> � E <br /> M <br /> OBSERVATIONS AND CORRECTIVE ACTIONS <br /> ., y. <br /> F 14 - x`17t C / � airs recd <br /> ter' /vvr air �� / AGI <br /> - as <br /> wa —0 - - <br /> r — Ok- on Locatem <br /> Temperature - <br /> Item/Location Temperature Item t Location TemperItem/ iTperature <br /> 4�4-n l,`--- a r �'� - --.38 <br /> Food Safety Certification _Facility Hot Water Temperature Warewashing <br /> Name: a r hke q6 �� Hand Sink: 2 of Chlorine: PPM Heat: 'F <br /> Exp.Date: /0 — _ arewashing Sink: 33 of Quat.Amm.: VZ) ppm Other: of <br /> Received By/Title: <br /> EH Specialist: _ Phone: <br /> time in- Time Out: 0'0 �*-) Page of <br /> EHD 16-24 (2nd pg) 4/9/12 FOOD PROGRAM OR CONTINUATION <br />