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oPa�IN• g SAN JOAQUIN COUNTY <br /> ?� ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> r• ;v Telephone: (209)468-3420 Fax:(209)464-0138 Web:www.siaov.org/ehd <br /> 4�IF0•M� <br /> FOOD PROGRAM OFFICIAL INSPECTION REPORT <br /> [Name of Facility: Date: 5_ ZRJdress: City: Zip Code: "WZ00 <br /> nerlOperator: o Telephone: <br /> gram Element: I . rogram Record: Inspection Type:180 Posted e\ No Permit Posted a No Re-Inspection on or Aker: <br /> OBSERVATIONS AND CORRECTIVE ACTION$ <br /> kjiAt <br /> Aj - <br /> 1 Item/Location _ ��Temperature- Item l:Location. kTemperature <br /> F..•ood:Safety Certification . _ Facility HotWater Temperature _ Warewa's g1 _ <br /> Name: Hand Sink: of Chlorine: ppm Heat: of <br /> Exp.Date: arewashmg- ink: eF Quat.Amm.: ppm Other: eF <br /> Received By I Title: <br /> EH Specialist: • Phone: 70''4. f —3q nl <br /> ime in: Time Out: F/ _�(�V Page of <br /> EHD 16-24 (21d pg) 413113 FOOD PROGRAM OIR CONTINUATION <br />