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oPAu!N,-c SAN JOAQUIN COUNTY <br /> �:•�••.off <br /> 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 /> U i+iS'n <br /> FOOD PROGRAM OFFICIAL INSPECTION REPORT <br /> Name of Facility: l o Date: t <br /> Address: City: Zip Code: <br /> Owner/Operator: ` Telephone: <br /> Program Element: Program Record: h t_ InspectionType: - <br /> SB180 Posted Yes Permit Posted Yes o 10 Re-Inspection on or After: <br /> OBSERVATIONS AND CORRECTIVE ACTIONS <br /> i <br /> LIP A&" S e <br /> _Aal <br /> Item/Location Temperature Item Location Temperature <br /> ood Safety Certification Facility Hot Water Temperature ` _ _ _ - Warewashing <br /> Name: - and Sink: of hlorine: ppm Heat: of <br /> Exp.Date: Iftrawashing Sink: eF P <br /> uat.Amm.: ppm Other: of <br /> Received By I Title: <br /> EH Specialist: h4 a Phone• <br /> ime In: Time Out: �•v Page of <br /> EHD 16-24 (2d pg) 4IN13 FOOD PROGRAM OIR CONTINUATION <br />