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SAN JOAQUIN COUN . <br /> X ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209)468-3420 Fax: (209)464-0138 Web:www.sigov.org/ehd <br /> /FORA <br /> FOOD PROGRAM OFFICIAL INSPECTION REPORT <br /> Name of Facility: Date: <br /> Address: City: Zip Code: <br /> Owner/Operator: Telephone: <br /> Program Element: Program Record: Inspection Type: (A- AIC1in <br /> SB180 Posted Cl Yes ❑ Rermit Posted ❑Yes ❑1 Re-Inspection on or After: <br /> OBSERVATIONS AND CORRECTIVE ACTIONS <br /> %&p cWrS ibrq ori- fihe _q- c.fi +VQ m t-�-e} <br /> VIS CW I n C) 0 '1'�li <br /> Item/Location Temperature Item/Location i Temperature <br /> ...................-_ ....... - —._.. .........- - - <br /> ----------- <br /> ME <br /> Name: Hand Sink: Chlorine. Ppm <br /> Facility Hot Water Temperature Warewashing <br /> ..__ _oF. <br /> Heat: °F <br /> Exp. Date: are ashing Sink: of Quat.Amm.: ppm 'Other: °F <br /> Received By/Title: <br /> EH Specialist: Phone: <br /> Time in: �U 1 5 F Time Out: 11 ;0 0 Page( of <br /> EHD 16-24(2n1 pg) 4/3/13 U FOOD PROGRAM OR CONTINUATION <br />