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SAN JOAQUIN CO. .TY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> • �q.. -.alp. Telephone:(209) 468-3420 Fax:(209)464-0138 Web:www.sl4ov.orq/ehd <br /> ��FOR <br /> FOOD PROGRAM OFFICIAL INSPECTION REPORT <br /> Name of Facility: C I Date: 1 <br /> Address: /7 2 f �^( City: Zip Code: <br /> C <br /> �` <br /> Owner/Operator: Telephone:Ci _ I C <br /> Program Element: �y� Program Record: 0OQ (1GC6j ' Inspection Type: Cr'1 ICAC <br /> SB180 Posted Yes No Permit Posted Yes No 1 Re-Inspection on or After: "�� <br /> din a i n S - -ire Q+ 1iv, �bul <br /> e a+ r\ b Q e nd u's Or,6 ChAn+y- <br /> rCA W-4 R <br /> U 1 i 5 Wrcefl�\ c - au --cam '0 "-a* o -h e, <br /> kj0r>_ rm uw Z-f-ed cJv-ems n m <br /> hecuu�e_ fi \.Ao�-F[ jn <br /> n avr S �� The,, <br /> 'Ch U'r nQ � c � t� �� U�cn- K_ qV a <br /> bCW+ c <br /> vs no ("0104e oy fi oo OCAMOW -W lhz�, � <br /> SCSM Che OV* k CAI� <br /> "-V is Unc` ti - <br /> -- K Gtr �� C G� (�nG �S C�crP,�l G <br /> v1 a a <br /> c°o m n v, �eStvr ani rens e � <br /> -f=ood Safety Certification a <br /> Name: Hand Sink: of Chlorine: ppm Heat: -F <br /> Exp.Date: arewashing Sink: of Ouat.Amm.: ppm Other: of <br /> Received By/Title: <br /> EH Specialist: Phone: — („ <br /> ime in: Time Out: ` -` u/ Page of <br /> U �5 FOOD PROGRAM OIR CONTINUATION <br /> EHD 16-24 (2n1 pg) 4/3/13 <br />