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4"'" SAN .IOAQUIN COUN <br /> )� cOG <br /> Q` 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 /> 4��FORa <br /> FOOD PROGRAM OFFICIAL INSPECTION REPORT <br /> Name of Facility: - Date: 12_U.A' <br /> Address: 14 - City: Zip Code: <br /> Owner/Operator:'! ✓ / /— Telephone: <br /> Program Element: Program Record: ty Inspection Type: <br /> SB180 Posted Yes No Permit Posted Yes No Re-Inspection on or After: <br /> OBSERVATIONS AND CORRECTIVE ACTIONS <br /> V%- - <br /> J <br /> In 0 4 144 41 <br /> Item/Location Temperature Item/Location Temperature <br /> Food Safety Certification Facility Hot Water Temperature Warewashing <br /> Name: Hand Sink: FF Chlorine: ppm Heat: °F <br /> Exp.Date: arewashing Sink: -F Ouat. Amm.: ppm Other: �F <br /> Received By/Title: 6�_ l/ <br /> EH Specialist: Phone: <br /> Time in: <br /> t.or�M Time Out: �r�S. Page of <br /> EHD 16-24 (2n4 pg) 4/3/13 FOOD PROGRAM OIR CONTINUATION <br />