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on44!%, SAN JOAQUIN COUNTY <br />Q' ? ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />... P. Telephone: (209) 468-3420 Fax: (209) 464-0138 Web: www.sioov.org/ehd <br />,Gi FdR� <br />FOOD PROGRAM OFFICIAL INSPECTION REPORT <br />Name of Facility: <br />Date: _ <br />Address: <br />C 0G Cit <br />Zip Code: <br />Owner/Operator: <br />Telephone: <br />Program Element: <br />Program Record: <br />Inspection Type: <br />6180 Posted <br />Yes No <br />Permit Posted Yes No <br />Re -Inspection on or After: <br />lk�S <br />d <br />Lc Ac IAIQ <br />W <br />Y c <br />S <br />b <br />eL <br />Rbc TRo o S <br />6-qC4M6 <br />&19AIb <br />S <br />p S -e' to <br />r <br />Pe <br />.Pereture ` <br />)CEO3 <br />IrVI � <br />2 <br />I O <br />=F hlorine: <br />PPM Heat: =F <br />ame: rt I and Sink: <br />�V <br />Exp. Date: <br />arewashing Sink: <br />'F Ouat. Amm.: <br />PPM <br />her: 'F <br />Received By/ Title: <br />EH Specialist: <br />EH <br />C <br />Phone: 205'—E6 <br />0 <br />E 6 r 2 <br />1 <br />In: <br />d . <br />Time Out: I <br />I • Z Page f <br />EHD 1624 (2n°pg) 4/3113 FOOD PROGRAM OR CONTINUATION <br />