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ENVIRONMENTAL HEALTH DEPARTMENT <br /> _ 68 East Hazelton Avenue, Stocktc 95205-6232 <br /> • c... P• Telep one:(209) 468-3420 Fax:(209) 464-013b w.eb:www.sogov.org/ehd <br /> 4��FORa� <br /> FOOD PROGRAM OFFICIAL INSPECTION REPORT <br /> Name of Facility:i 19 4Dn Iin kn <br /> Date: <br /> Address: S City: 1 Zip Code: <br /> Owner/Operator: 7� Telephone: <br /> Program Element: Program Record: S Inspection Type:r .tiW ' <br /> SB180 Posted Yes No Permit Posted Yes No Re-Inspection on or After: <br /> y 3 S h r <br /> AK <br /> Uf <br /> `v�s2 '�� —,cvv�.1c � S l•� <br /> L\25 <br /> i V 1--: <br /> '2 <br /> Item/Location Temperature )tem I Location Temperature <br /> Food Safety Certification Facility Hot Water Temperature Warewashing <br /> Name: Hand Sink: of Chlorine: ppm Heat: =F <br /> Exp.Date: Warewashing Sink: of Quat.Amm.- PPM Other: of <br /> Received By/Title � �� <br /> EH Specialist: Phone: 4 10 O z <br /> Time in: Time Out: l�� �� J Page of <br /> EHD 16-24 (2n"pg) 4/3/13 FOOD PROGRAM OIR CONTINUATIOP <br />