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oPa SAN JOAQUIN COUNT <br /> °A ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> .. -. Telephone:(209)468-3420 Fax.(209)464-0138 Web:www.smaov.org/ehd <br /> 4�/FORS <br /> FOOD PROGRAM OFFICIAL INSPECTION REPORT <br /> Name of Facility: Date: 12,11'1,1 <br /> Address: City: Zip Code: 2 <br /> Owner/Operator: Telephone: <br /> �. <br /> Program Element: Pro m Reeord: t7 s () Inspection Type: <br /> 8180 Posted Yes No Permit Posted Yes No Re-Inspection on or After: <br /> OBSERVATIONS AND CORRECTIVE ACTIONS <br /> Cv <br /> 00 <br /> Y � / <br /> S <br /> -- T _. <br /> itemlLocation Temperature ,._item/Location Temperature <br /> Food Safety Certification Facility Hot Water Temperature Wareviashing <br /> Name: Hand Sink: of Chlorine: PPm Heat: -F <br /> Exp.Date: 1warewashing Sink: of uat.Amm.: PPm Other: -F <br /> Received By/Title: <br /> EH Specialist: Phone: <br /> ime in: ! / Time Out: O Page of <br /> EHD 16-24(2^ pg) 413113 FOOD PROGRAM OR CONTINUATION <br />