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Pg"I" SAN JOAQUIN COUI ' <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209) 468-3420 Fax:(209) 464-0138 Web:www.sipov.orq/ehd <br /> ��FORN <br /> FOOD PROGRAM OFFICIAL INSPECTION REPORT <br /> Name of Facility: Vl r\ (rt-, p Date: , 16 <br /> Address: , IAL (re W Pr 1 City: j I, r 7 Zip Code: C S 33 G <br /> Owner/Operator: A; C hu r d 140yr, h Telephone: q y <br /> Program Element: y Program Record: Inspection Type: <br /> SB180 Posted Yes No Permit Posted Yes No Re-Inspection on or After: <br /> OBSERVATIONS AND CORRECTIVE ACTIONS <br /> Josie 11; 0101 Ila ns Ccrrcckcd <br /> I o a K IA) a r IYl W, f e r n Qnlk b, 4c,,d O ^ <br /> G o <br /> 3 Pie plIu to I e h G s a b o Il Pti d b <br /> i n e r IC <br /> 9031rocrn 4 fr. cIC Self Cros,, r, r+12 U ; r <br /> C 1 dM a r� p d PC,C <br /> �G /Pr- C,/,d, raw. C p ; l r\ .2 W.- c' <br /> C is , V. dor •Jgo i , k/% "'i <br /> Cal dcy 10 C l a ks: <br /> Item/Location Temperature Item!Location Temperature <br /> Food Safety Certification Facility Hot Water Temperature Warewashing <br /> —._....._......---- ---___...._..:_.._.._..._...._-- ---._..----------- <br /> Name: Hand Sink: -F Chlorine: ppm Heat: F <br /> Exp. Date: Warewashing Sink: of Quat. Amm.: ppm Other. F <br /> Received By/Title: <br /> EH Specialist: Phone: 416e j 14 f <br /> Time in: i - Time Out: 2 Page of <br /> i <br /> EHD 16-24 (2n'pg) 4/3/13 FOOD PROGRAM OR CONTINUATION <br />