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SAN JOAQUIN COW <br /> a` ENVIRONMENTAL HEALTH DEPARTMENT <br /> X <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> • c.., �P• Telephone:(209) 468-3420 Fax:(209) 464-0138 Web:www.segov.org/ehd <br /> 'QCj F ORc� <br /> FOOD PROGRAM OFFICIAL INSPECTION REPORT <br /> Name of Facility: / Date: d —1 <br /> Address: " l A g zY City: 40 Zip Code: O.- <br /> ?-Owner/Operator: Telephone: <br /> Program Element: Program Record: to3 Inspection Type: <br /> SB180 Posted Yes No Permit Posted Yes No Re-Inspection on or After: <br /> 77 <br /> CfBSEtVA S AI+�G3REC flYICTtONS <br /> (i/'1 <br /> 1\ 5 <br /> 7- Tto no Lr "c-­7 <br /> C R d `5O e <br /> /-» <br /> .� <br /> S 30 <br /> Qc- sx- a � <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 /> r <br /> EH Specialist: Phone: <br /> Time in: n Time Out: JDJ� J Pa of <br /> EHD 16-24 (2ntl pg) 4/3/13 FOOD PROGRAM OIR CONTINUATION <br />