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SAN JOAQUIN COUNTY <br /> ?a ENVIRONMENTAL HEALTH DEPARTMENT <br /> m 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209)468-3420 Fax: (209)464-0138 Web:www.siaov.orq/ehd <br /> C/PORN <br /> FOOD PROGRAM OFFICIAL INSPECTION REPORT <br /> Name of Facility: - ^ Date: _ _ <br /> Address: � i City:.— Zip Code: Ci <br /> Owner/Operator: V Telephone: <br /> Program Element: Program Record: Z Inspection Type: <br /> SB180 Posted Yes No Permit Posted Yes No Re-Inspection on or After: <br /> OBSERVATIONS AND CORRECTIVE ACTIONS <br /> t� <br /> Item/Location Temperature Item/Location Temperature <br /> Food Safety Certification Facility Hot Water Temperature Warewashing <br /> Name: Hand Sink: of Chlorine: ppm Heat: of <br /> Exp.Date: Warewashing Sink: of Quat.Amm.: ppm Other: of <br /> Received By/Title: <br /> wLl o 1 1 �a �U�� ti <br /> EH Specialist: Phone: <br /> Time in: Time Out: �' 1 Page of <br /> EH 16-24 (2nd pg) 413113 1 FOOD PROGRAM OIR CONTINUATION <br />