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<br />SAN JOAQUIN COUNTY
<br />ENVIRONMENTAL HEALTH DEPARTMENT
<br />1868 East HazeIton Avenue, Stockton, CA 95205-6232
<br />Telephone: (209) 468-3420 Fax: (209) 464-0138 Web: www.siqov.orq/ehd
<br />FOOD PROGRAM OFFICIAL INSPECTION REPORT
<br />Name of Facility: Date:
<br />ddress: N , _ . 1 , 0 (die f c d\( 1/1) Clui
<br />City: .-- / ., Zip Code:
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<br />Owner/Operator: Telephone:
<br />Program Element: Program Record: if /' Inspection Type: a ce7 4 --7-/ s ilt
<br />C4 1-1-0..._ SB180 Posted Yes No Permit Posted Yes Re-Inspection on or After:
<br />OBSERVATIONS AND CORRECTIVE ACTIONS
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<br />Item/Location Temperature Item / Location Temperature
<br />, Food Safety Certification Facility Hot Water Temperature Warewashing
<br />Name:
<br />4 4( -4147 I to-i, 4:o Hand Sink: .F Chlorine: ppm Heat: oF
<br />Exp. Date:
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<br />Warewashing Sink: .F Quat. Amm.: ppm Other: °F
<br />Received By / Title:1 ?-5 c1/i4 ocq
<br />'fry, - Iiil, EH Specialist: ' Phone: ....T1,, 9 95 3 :7 -1‘ r 8
<br />Time in: rr-- Time Out: Page of
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<br />EHD 16-24 (2., pg) 413113 FOOD PROGRAM OIR CONTINUATION
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