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SAN JOAQUIN COL Y <br /> za ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209) 468-3420 Fax: (209)464-0138 Web:www.s*gov.org/ehd <br /> <<FORN <br /> FOOD PROGRAM OFFICIAL INSPECTION REPORT <br /> Name of Facility: Date: <br /> Address: City: Zip Code: <br /> Owner/Operator: Telephone: <br /> Program Element: Program Record: Inspection Type: <br /> SB180 Posted Yes No Permit Posted Yes No Re-Inspection on or After: <br /> 101 <br /> wa <br /> M a <br /> IG v1nv: <br /> \A,F CCkW . artoVqfl -D fibe, 'PLA �Ic, a or-2 <br /> haft bah - �vv�r <br /> , IDYL <br /> q <br /> fin r� Ltn C W � <br /> \\16 <br /> �Tny- <br /> es CM SAS <br /> CA t WC vN wi--ti wQ�_" VvOWT <br /> wt <br /> r, r.� Ct�v� - • �r su <br /> \A 4- CO <br /> deS �Urr1` S GAf PiN-P o'cIt- - T) WTAC <br /> nii-hp 1 ova <br /> G , <br /> .41 <br /> �. <br /> Name: Hand Sink: of Chlorine: ppm Heat: of <br /> Exp.Date: Warewashing Sink: of Quat.Amm.: ppm Other: of <br /> Received By/Title: <br /> EH Specialist: Phone: <br /> Time in: Time Out: Pag of . <br /> EHD 16-24 (21^pg) 4/3/13 FOOD PROGRAM OIR CONTINUATION <br />