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4"'" SAN JOAQUIN COUNT <br /> )� c�G <br /> w: X <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> • cq.. ;P• Telephone:(209) 468-3420 Fax:(209) 464-0138 Web:www.siaov.orp/ehd <br /> �iFOR <br /> FOOD PROGRAM OFFICIAL INSPECTION REPORT <br /> Name of Facility: Date: l �2 <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 /> INI-«, ; ,�� -,.;,�,� -� d""� � �z � 4RE <br /> mast <br /> i <br /> 1' <br /> bi <br /> Item/Location Temperature Item 1 Location Temperature <br /> T Food Safety Certification Facility Hot Water Temperature Warewashing <br /> Name: Hand Sink: of Chlorine: ppm Heat: of <br /> Exp.Date: Warewashing Sink: of Ouat.Amm.: ppm Other: of <br /> Received By/Title: <br /> EH Specialist: Phone: <br /> Time in: Time Out: I - Page f;of <br /> EHD 16.24 (2n1 pg) 4/3/13 FOOD PROGRAM OIR CONTINUATION <br />