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PQu�k SAN JOAQUIN COL -Y <br /> X ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209)468-3420 Fax:(209) 464-0138 Web:www.slgov.org/ehd <br /> ��FORN <br /> FOOD PROGRAM OFFICIAL INSPECTION REPORT <br /> Name of Facility: Date: <br /> Address: City: Zip Code: <br /> Owner/Operator: P Luf� Telephone: <br /> Program Element: Program Record: ' Inspection Type: <br /> FIB-180—Posted Yes No IPermit Posted Yes No Re-Inspection on or After: / <br /> OBSERVATIONS AND CORRECTIVE ACTIONS <br /> ✓i I r <br /> LVV✓tet- o- - <br /> r� a <br /> Wy-yu'vvyA `71 <br /> /V qtoj <br /> a 77 ✓t.�n <br /> Item/Location Temperature Item!Location Temperature <br /> Food Safety CertificationFacility Not Water Temperature Warewashing <br /> Name: Hand Sink: "F Chlorine: ppm Heat: of <br /> Exp.Date: �Warewashing Sink: of Quat. Amm.: ppm Other: of <br /> Received By/Title: r <br /> EH Specialist: Phone: <br /> Time in: Time Out: Page;of <br /> EHD 16-24 (2'd pg) 4/3/13 FOOD PROGRAM OIR CONTINUATION <br />