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1 <br /> 'aha c°o SAN �OAQlJIIV C011 *'Y <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> X <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> • c4..:: -.�;P.. Telephone:(209) 468-3420 Fax: (209) 464-0138 Web:www.sagov.org/ehd <br /> I <br /> �r�oa <br /> FOOD PROGRAM OFFICIAL INSPECTION REPORT <br /> Name of Facility: ct 4:o- 0,4Date: I0"11-1 <br /> Address: r- v ity: G• Zip Code: <br /> Owner/Operator: 00 }_ Telephone: /; W— <br /> Program Element: Q+� Program Record: �O� Inspection Type: w i'Y <br /> SB180 Posted Yes No Permit Posted Yes No Re-inspection on or After: cif <br /> re I"Y7 O Cf 6:5 <br /> wkR, <br /> .,K K cvlrQr r <br /> Dh <br /> SPrt. hon : i 4 rr»cLe 1 u C?a�r �' . <br /> o ba �' <br /> aklca(_ Ko 171 ezr`. <br /> ; Shia 1.-C Lt- bonaI26� <br /> b _I r -1-Q c� F_/Wrs <br /> 010 aaQ-4 rpm 'r"' <br /> Sr <br /> i <br /> r io <br /> � ;.�.�,�_. �� - � � ...- �7�ierattc�t E,�- � ���elP�i�♦wca�a�p�e...� .t_�... a '�'Cntat�T��' <br /> ttert�I�ocatioti .. .- <br /> Name: Hand Sink: of Chlorine: ppm Heat: of <br /> Exp. Date: Warewashing Sink: aF Quat.Amm.: ppm Other: of <br /> Received By!Title: O y <br /> EH Specialist: , Phone: 5 <br /> Time in: Time Out: /` • 0 Page/of , <br /> FHS 16-24 (21d pg) 413113 / C/ FOOD PROGRAM QIR CONTINUATION <br />