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�'"'"• SAN JOAQUIN COUP' <br /> )a d-slto c•P4 <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> 4tl dA�;. Telephone:(209)468-3420 Fax: (209)464-0138 Web:www.siaov.org/ehd <br /> FOOD PROGRAM OFFICIAL INSPECTION REPORT <br /> Name of Facility: Date: <br /> Address: a 51 If S u� City: Zip Code: <br /> Owner/Operator: roq Telephone: <br /> Program Element: 03.Z Program Record: In ection Type: CZ <br /> 8180 Posted Yes No Permit Posted Yes No Re-Inspection on or After: <br /> OBSERVATIONS AND CORRECTIVE ACTIONS <br /> I If <br /> b n aZ2� <br /> Item/Location Temperature Item/Location Temperature <br /> Dpi <br /> Food Safety Certification Facility Hot Water Temperature Warewashing <br /> Name: Hand Sink: 'F hlorine: PPM Heat: "F <br /> Exp.Date: arewashin Sink: 'F Puat.Amm.: PPM they: 'F <br /> Received By/Title: <br /> EH Specialist: Phone: L <br /> Time in: Time Out. n-f1 Page of <br /> EHDI624 (2-pi) 4/3113 V V FOOD PROGRAM OIR CONTINUATION <br /> C <br />