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SAN JOAQUIN COL Y <br /> t� ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209) 468-3420 Fax: (209)464-0138 Web:www.sioov.org/ehd <br /> 4/POk' <br /> FOOD PROGRAM OFFICIAL INSPECTION REPORT <br /> Name of Facility: {') — Date: <br /> Address: a City: Zip Code: <br /> QUbur� 5.2,M3Owner/Operator: <br /> Telephone:5 _ <br /> Program Element: Q3 Program Record: 1 OO Inspection Type: SSV <br /> 8180 Posted Yes No Permit Posted Yes No Re-Inspection on or After: <br /> OBSERVATIONS AND CORRECTIVE ACTIONS <br /> t rn s r (,e r n..o+ ot.ua: hog <br /> Y r-H C <br /> © :2rou-;aR -Fooa r <br /> r.' < re Llxa s 1 0 <br /> rp tri -- n a mE- b w" r <br /> 'n C-A AA kAkV <br /> n.i U <br /> P <br /> VydrAfO1 m 1 (0-7J3 15 eY rr�i <br /> iD n d i-1-i o n ) 5 h Al l lae <br /> L� c. I K fl042 '39 <br /> ftem/Location Temperature Item!Location Temperature <br /> 2L0 oCn r 410017 <br /> Food Safety Certification Facility Hot Water Temperature Warewashing <br /> Name: and Sink: 10 I 'F Chlorine: Ppm eat: 'F <br /> Exp.Date: arewashing Sink: 'F uat.Amm.: Ppm ther: -F <br /> Received By/Till <br /> EH Specialist: Phone: <br /> Time in: Time Out: L/ Pagel of I <br /> EHD 16-24 (2-Pg) 4343 �J FOOD PROGRAM OIR CONTINUATION <br /> tYO53�6�1Z <br />