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oPa+!n SAN JOAQUIN COUNTY <br /> ?� ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209) 468-3420 Fax: (209)464-0138 Web:www.si ov.orq/ehd <br /> GI FORT? <br /> FOOD PROGRAM OFFICIAL INSPECTION REPORT <br /> Name of Facility: QC.0 50 r) c5(i�-100 I Date: <br /> Address: n O W Kava na h City: Tlr ac.� Zip Code: p <br /> caner/Operator. u Telephone: <br /> Program Element: .�Sb Program Record: P R O I Inspection Type:I(a „ V-Di,;ria.. <br /> B180 Posted 4Yes ❑ No Permit Pos;teN Yes ❑ No Re-Inspection on or After: <br /> U 00 U-P- pa.i ir b m d-)-t4--h <br /> n1 Fa <br /> K co o <br /> Fe o d vJ cw r,t 16#71= <br /> Name: and Sink: /21oF Chlorine: ppm Heat: •F <br /> Exp.Date: / i 5 � arewa In ink: 1 a�`F t.Am 4 ppm Other. 'F <br /> Received By/Tit ' <br /> EH Specialist: kA-_ 1 Phone: 15?2-39/7 <br /> Time in: ✓ 7 Time Out L b ' 2-0, 2-0 Pageyof <br /> EHD 16-24(2°pg) 4/3/13 FOOD PROGRAM OR CONTINUATION <br />