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,oP4 .sA� SAN JOAQUIN COUNTY <br /> ' ENVIRONMENTAL HEALTH DEPARTMENT <br /> a 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209)468-3420 Fax:(209)464-0138 Web:www.siuov.orct/ehd <br /> �rFOR� <br /> FOOD PROGRAM OFFICIAL INSPECTION REPORT <br /> Name of Facility: Date: <br /> ddress: City: Zip Code: <br /> Owner/Operator: Telephone: <br /> Program Element: Program Record: Inspection Type: <br /> 58180 Posted Yes No Permit Posted Yes No Re-Inspection on or After: <br /> OBSERVATIONS AND CORRECTIVE ACTIONS <br /> V"•J l:` <br /> 1 <br /> ItemlLocatidn Temperature Item I Locatio Temperature <br /> JJ <br /> J� 1 _ — <br /> __Food Safety Certification Facility Hot.Water Temperature -. Warewashing <br /> Name: Hand Sink: of Chlorine: ppm Heat: of <br /> Exp. Date: arewashing Sink: DF oust.Amm.: ppm Other: eF <br /> Received By I Title: <br /> EH Specialist: Phone: - <br /> ime in: Time Out: -y Page of <br /> -7T_t J ' <br /> EHD16-24 (2^ pg) 413113 1 FOOD PROGRAM OIR CONTINUATION <br /> S <br />