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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.siaov.oro/ehd <br />FOOD PROGRAM OFFICIAL INSPECTION REPORT <br />Name of Facility: <br />Date: <br />— 20 _ z <br />Address: <br />I N 5—r„ City: <br />5..r,7 C -k Zip Code: <br />957-16; <br />Owner/Operator: <br />Telephone: <br />Program Element: Program Record: <br />Inspection Type: <br />RoU rkN'E <br />Set 80 Posted Yes No Permit Posted Yes No <br />Re -Inspection on or After: <br />O <br />SERVATIONS AND CORRECTIVE ACTIONS <br />77. 8 L <br />✓ <br />Fav <br />H V 400S'7—�O <br />aLs <br />CL -16 <br />•S <br />t -rWle bN <br />e0o <br />S— <br />cSC <br />5.D A mtssvAj< e <br />L A.r <br />wim- <br />/Ar 2 <br />1tem/Locatl <br />perature <br />tem / LoCaiton <br />D Goo <br />�., Food.Safety Certfflcation <br />ility Hot Water Temperature <br />':. Warew i <br />Chlorine: ppm Heat: eF <br />Name: 13 L{, M • �kl <br />nk: 1 �.� �p <br />rarewashing <br />Exp. Date: c)?.— t 3 Zt5 <br />Sink: 3 <br />=p <br />Ouat. Amm.: ppm <br />Other: �p <br />Received By/ Title: <br />EH Specialist: CJq <br />l.-/94J� <br />U <br />Phone: <br />�7 <br />Time in: O • C O A M <br />Time out: / 0 : So A A4 <br />Page 2. 2 <br />EHD 16-24 (21' pg) 413113 FOOD PROGRAM OIR CONTINUATION <br />