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SAN JOAQUIN COUNTY <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 />FOOD PROGRAM OFFICIAL INSPECTION REPORT <br />Name of Facility: <br />Date: (—, Z— Z <br />Address: \ \�1 <br />` <br />City: <br />Zip Code: <br />Owner/Operator: <br />C <br />\ <br />Telephoners -21 _5;:f <br />Program Element: <br />Program <br />Record: 5 R 0 1 <br />Inspection Type: <br />SB180 Posted Yes No <br />Permit Posted Yes No <br />Re -Inspection on or After: <br />!� LIM <br />S <br />SERVATIONS AND CQR@ILCTlVE <br />ACTIONS <br />CT� TS <br />4eC5 <br />M <br />,"o, <br />2 <br />a <br />2 <br />rnr Q <br />C� inn <br />54p <br />{: 2 <br />Ci. <br />S i cSLP <br />f S C-, <br />10, <br />eo.r��e <br />Inv <br />ZJ©L <br />V <br />_ - <br />\ Jcrr� <br />' in / Locatio7rn <br />Food safety Certification <br />Name: <br />Exp. Date: <br />Facility Hot Water Temperature <br />and Sink: Q.,/ 11 1 Chlorine: <br />arewashing Sink: t� F oust kmm.: <br />Warewashing <br />ppm Heat: �F <br />ppm Other: -F <br />Received By/ Title: f <br />V <br />EH Specialist: <br />Phone: <br />_ 1 Z <br />Time in: <br />Time Out: <br />�. 1 Pagg if 2 <br />EHD 1644 (2' pg) 4013 FOOD PROGRAM OIR CONTINUATION <br />