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SAN JOAQUIN Cour <br /> z y ENVIRONMENTAL HEALTH DEPARTMENT <br /> 4: .a <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> �4. ;P Telephone:(209) 468-3420 Fax:(209)464-0138 Web:www.sigov.or /q ehd <br /> iii dad <br /> FOOD PROGRAM OFFICIAL INSPECTION REPORT <br /> Name of Facility: Date: 112-11 <br /> Address: / 107 I/Lq City: I-1 S <br /> Zip Code: � L) <br /> Owner/Operator: ' u 2DTelephone: <br /> Program Element: 1 Program Rec d: 2• In pection Type: <br /> S8180 Posted Yes No Permit Posted Yes No Re-Inspection on or After: <br /> OBSERVATIONS AND CORRECTIVE ACTIQNS <br /> j7 Z <br /> r <br /> i <br /> — -- — <br /> Item/Location ocation Temperature - <br /> Item Location Temperature <br /> Food Safety Certification <br /> Facility Not Water Temperature irJarewashing <br /> Name: Hand Sink: `F Chlorine: ppm Heat: °F <br /> Exp.Date: Warewashing Sink: °F Quat. Amm.: ppm Other: °F <br /> Received By/Title: <br /> EH Specialist: Phone: <br /> Time in: Time Out: S Page of <br /> r <br /> EHD 16-24 (2n°pg) 4013 FOOD PROGRAM OR CONTINUATION <br />