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SAN JOAQUIN COON' <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209) 468-3420 Fax:(209) 464-0138 Web:www.sigov.org/ehd <br /> <<FORN <br /> FOOD PROGRAM OFFICIAL INSPECTION REPORT <br /> Name of Facility: ,�.. -z Date: 2 �[ <br /> Address: AO ,nGy I City: LT Zip Code: <br /> Owner/Operator: // V Telephone: 2 <br /> Program Element: Z Program Record: , Inspection Type <br /> 0 LN <br /> SB180 Posted Yes No Permit Posted &Yes No Re-Inspection on or After: <br /> OBSRVATIt�NS ANL?t"rC�RREt:TtVE i4C Tlt)NS <br /> ..�4'. ., .. .. <br /> d a - <br /> Y"/ ve- <br /> w � w <br /> X-P a <br /> va- <br /> Item/Location Temperature Item Location I U Temperature <br /> r <br /> � • � ��Vr 1� �9 <br /> Food°Safe y Certification Facility Not Water Temperature Warewashing <br /> Name: 1 Hand Sink: of Chlorine: ppm Heat: 112 of <br /> Exp.Date: Warewashing Sink: Z of Quat.Amm. ppm Other: 'F <br /> Received By/Title: <br /> EH Specialist: Phone: <br /> Time in: i/ Time Out: 1 Page <br /> EHD 16-24 (2,a pg) 4/3/13 FOOD PROGRAM OR CONTINUATION <br />