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*IL <br /> a�!y JOAQUIN COUNU <br />� oR• -•.o SAN , <br /> z ? ENVIRONMENTAL HEALTH DEPARTMENT <br /> ta. <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-62,32 <br /> • c°tr SRa` .. Telephone: (209) 468-3420 Fax: (209) 464-0138 Web:www.s ov.or lehd <br /> �o <br /> FOOD PROGRAM OFFICIAL INSPECTION REPORT <br /> Name of Facility: Date <br /> IX �3 �� <br /> Address: h City: Zip Code: <br /> Owner/Operator: Telephone: <br />` Program Element: Program Record: �kn ' Inspection Type: <br /> B180 Posted D Yes ❑ Rermit Posted D Yes ❑ r Re-inspection on or After: <br /> �... ' <br /> f 2&I 1� r — S` m <br /> k <br /> a <br /> � r <br /> Vh <br /> f2i <br /> a <br /> � o <br /> I <br /> 1. <br /> #rte: <br /> Name: Hand Sink: -F Chlorine: ppm Heat: `F <br /> Exp.Date: Warewashing Sin -F Quat.Amm.: ppm Other: 'F <br /> Received By!Title: <br /> r <br /> EH Specialist: - Phone: <br /> Time in: j I. <br /> Time Out: Page of <br /> 1 <br /> EHD 1fi-24 (21eP9) 413113 FOOD PROGRAM OIR CONTINUATION <br />