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anaY'" SAN JOAQUIN COU1 <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />®_ 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />.. P Telephone: (209) 468-3420 Fax: (209) 464-0138 Web: www.sigov.org/ehd <br />9CIFOPt <br />L <br />PROGRAM OFFICIAL INSPECTION REPORT <br />ame of Facility: <br />_ <br />Date: <br />13 <br />ddress: <br />City: <br />Zip Code: <br />wner/Operator: <br />Telephone: <br />Program Element: <br />Program Record: <br />Inspection Type: <br />B18O Posted 0 Yes 0 No <br />Permit Posted ❑ Yes No Re -Inspection on or After: <br />OBSERVATIONS AND CORRECTIVE ACTIONS <br />".. <br />r <br />M <br />A <br />Item/Location <br />Temperature Item / Location Temperature <br />Item! Location <br />Temperature; <br />Food Safety Certification .., Facil` wY Water Temperature _ ..,. <br />Warewashing <br />Name: <br />Hand Sink: aFChlorine: <br />PPM <br />Heat: <br />of <br />Exp. Date: <br />arewashing Sink: eF uat. Amm.: <br />PPM <br />Other: <br />of <br />Received By/ Title: <br />EH Specialist: <br />Phone: , <br />`-02 <br />✓ <br />Time in:11 <br />Time Out; // V <br />Pag 1 <br />EHD 16-24 (2^ pg) 4N12 FOOD PROGRAM OIR CONTINUATION <br />