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Jk Date: <br />Owner/Operator:Telephone: <br />T <br />C <br />) <br />i cro <br />Item/Location Item / Location <br />Food Safety Certification <br />Chlorine:Name:ppm <br />Exp. Date:Warewashing Sink:Quat. Amm.:Other:PPm <br />Phone: <br />Time in:Time Out: <br />EHD 16-24 (2"° pg) 4/3/13 <br />7 <br />1M / <br />____! <br />San Joaquin Coi ;y <br />Environmental Health Department <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 464-0138 Web: www.siqov.org/ehd <br />C kj c < j rrx <br />Warewashing <br />Heat: <br />Name of Facility: <br />Address: <br />Tcpm / <br />°F °F <br />OBSERVATIONS AND CORRECTIVE ACTIONS <br />- \^AAxJ(O.. <br />iaeceived By <br />EH Specialist: i A . ZyCi <br />°F <br />| Temperature <br />Facility Hot Water Temperature <br />Hand Sink: op <br />Program Record: <br />Yes No <br />Temperature <br />HOF <br />r <br />Program Eleme^2 <br />SB180 Posted Yes No Permit Posted <br />'^£PbZ/ <br />Zip Code: <br />Inspection Type: <br />Re-Inspection on or After: ' <br />Pagc-^ 2 <br />FOOD PROGRAM 0IR CONTINUATION <br />4.Q) 5cxcv—pRqz7 - V\/J f( <br />5 <br />Food Program Official Inspection Report <br />fXWA-’ <br />City: <br />f CKj ' -5 f <br />___S \aJ . <br />RAW <br />s V-A . p-Q <br />IcAmI *fX