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oPa"`" .� SAN .IOAQUIN COUNTY <br /> z. ENVIRONMENTAL HEALTH DEPARTMENT <br /> ai <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> �;.., m �` Telephone: (209) 468-3420 Fax: (209)464-0138 Web:www.siqov.orq/ehd <br /> 4�FOF <br /> FOOD PROGRAM OFFICIAL INSPECTION REPORT <br /> Name of Facility: 1A C Date: y (p <br /> Address: �6 `Xn(Jn � �.- ,f,`R City: Zip Code: <br /> Owner/Operator:L, /1 , 1,. �, ' Telephone: <br /> Program Element: (•V Program Record: l� 1 Inspection Type: <br /> / / T <br /> SB180 Posted ❑Yes ❑ Rermit Posted ❑Yes ❑ 1 Re-Inspection on or After: ' <br /> OYI IIS L[0(v <br /> S: Pm a <br /> ✓� c E <br /> v\A- at pv( At <br /> ,v" d <br /> rn <br /> a d <br /> ✓1 Wvt <br /> urc <br /> a <br /> __ _� <br /> Name' and Sink: of hlorine: Ppm eat: of <br /> Exp. Date: rVar9washing Sink: "F Quat.Amm.: ppm Cher. of <br /> L <br /> d By I Title: <br /> cialist: Phone: <br /> : Time Out: �' Page of <br /> EHD 1624(2-pg) 413113 FOOD PROGRAM OIR CONTINUATION <br />