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o.Pawtg..e SAN JOAQUIN COUNTY <br /> � aG <br /> U): X <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazeiton Avenue, Stockton, CA 95205-6232 <br /> • •.. ;P• Telephone:(209) 468-3420 Fax:(209) 464-0138 Web:www.sjgov.org/ehd <br /> 4��FORN <br /> FOOD PROGRAM OFFICIAL INSPECTION REPORT <br /> Name of Facility: mom Date: <br /> Address: City: Zi ode: V <br /> l <br /> Owner/Operator: amp) ,_1 Telephone: <br /> Program Element: a Program Record: 1 Inspection Type: <br /> SB180 Posted Yes No Permit Posted Yes No Re-Inspection on or After: <br /> or <br /> 4g <br /> _ - (I <br /> 4,—n o 12 s �- 1211 <br /> Item/Location Temperature Item!Location Temperature <br /> Warewashin <br /> ,.Food Safety Certiflcation Facility Hot Water Temperature g <br /> Name. Hand Sink: of Chlorine: ppm Heat: -F <br /> Exp.Date: arewashing Sink: of Quat.Amm.: ppm Other: �F <br /> Received By/Title: <br /> EH Specialist: Phone: e <br /> Time in: <br /> Time Out: Page f <br /> FOOD PROGRAM OIR CONTINUATION <br /> EHD 16-24 (2°1 pg) 4/3/13 <br />