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Qvlry..X' SAN JOAQUIN COUP <br /> Z, ENVIRONMENTAL HEALTH DEPARTMENT <br /> N: :C <br /> _ 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> • c4.. _. iP• Telephone:(209) 468-3420 Fax:(209)464-0138 Web:www.s'gov.org/ehd <br /> �i FORa <br /> FOOD PROGRAM OFFICIAL INSPECTION REPORT <br /> Name of Facility: Date: G 3 <br /> Address: City: Zip Code: <br /> Owner/Operator: ✓ �"' Telephone: .7 <br /> Program Element: !_�S Program R ord: 0-L Inspection Type: <br /> SB180 Posted Yes No Permit Poste z Yes No Re-Inspection on or After: <br /> OBSERVATIONS AND CORRECTIVE ACTIONS <br /> 0 V <br /> �s <br /> n <br /> food Safety Cerfifc`ation;" #ac of Water: etnp, rs <br /> w . <br /> Name: Hand Sink: of Chlorine: ppm Heat: of <br /> Exp.Date: Warewashing Sink: 'F Quat.Amm.: Ppm Other: 'F <br /> Received By/Title: <br /> EH Specialist: `J� _ Phone: (fin,� _ ,U3 <br /> Time in: 1 -` Time Out: //4 3,5- Pa of ; <br /> EHD 16-24 (2n1 pg) 4/3/13 , FOOD PROGRAM OIR CONTINUATION <br />