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SAN JOAQUIN COUP' <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> - 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> �4•... ,..�;:P Telephone:(209) 468-3420 Fax:(209) 464-0138 Web:www.si, ov.or /q ehd <br /> �lFOR <br /> FOOD PROGRAM OFFICIAL INSPECTION REPORT <br /> Name of Facility: l j Jay Date: <br /> Address: City: Zip Code: <br /> Owner/Operator: Telephone: <br /> Program Element: Program Record: Inspection Type, <br /> SB180 Posted Yes No Per Posted Yes No Re-Inspection on or After: <br /> OBSERVATIONS AND CORRECTIVE ACTIONS <br /> ................-- <br /> r <br /> ltemiLoca>t#orT T Item Location. 7*— <br /> f`ooCl$a#e rert�ficuon yFaci# Hot ,em Waterrature Wa�rewashing ;s <br /> tY -�....�_. .. ..:. <br /> Name: Hand Sink: of Chlorine: ppm Heat: of <br /> Exp.Date: Ware hing Sink: of Quat.Amm.: Ppm Other: of <br /> Received By/Titl . f <br /> t 1 <br /> EH Spec' Phone: <br /> Ti in: 9 •i5i Time Out: O- Pagg f <br /> EHD 1&24 (2n°pg) 4/3113 FOOD PROGRAM OR CONTINUATION <br />