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oPQ�t"' SAN JOAQUIN COUNT <br /> Q' :2 <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209) 468-3420 Fax:(209) 464-0138 Web:www.siaov.org/ehd <br /> FOOD PROGRAM OFFICIAL INSPECTION REPORT <br /> Name of Facility: <br /> Date: <br /> Address: / City: Zip Code: <br /> Owner/Operator: Telephone: <br /> Program Element: Program Record: Q/� O Inspection Type: <br /> SB180 Posted Yes No Permit Posted Yes No Re-Inspection on or After: <br /> e_. OBSERV Mnl_ aypSE ra TIONS ,. :.-LL <br /> _4 c r rGrf <br /> - 4. T G.✓� <br /> ee <br /> " ,!/ - <br /> Item/Location Temperature Item/Lacaha', <br /> - _ <br /> " Food Sa ety Certification ` Facility Hot Water Tem" <br /> Name: Hand Sink: /O� a °F hlorine: ppm °F <br /> Exp.Date: arewashing Sink: °F uat.Amm.:O���/ ther: <br /> °F <br /> Received By/Titl <br /> EH Specialist: Phone: <br /> os <br /> Time in: /. QS Time Out: Pa ewof <br /> EHD 1624 (T°pg)4013 FOOD PROGRAM OR CONTINUATION <br />