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a"!" SAN .JOAQUIN COUP <br /> 4 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.sigov,org/ehd <br /> LIFOR <br /> FOOD PROGRAM OFFICIAL INSPECTION REPORT <br /> Name of Facility: - Date: -2_ <br /> Address: City: Zip Code: 01 S 2_�'4 <br /> Owner/Operator: S !� !� Telephone:3b _ <br /> Program Element: 2 N Program Record: Si Inspection Type: <br /> SB180 Posted es No Permit Posted Yes No Re-Inspection on or After: <br /> OBSERVATIONS AND CORRECTIVE ACTIONS <br /> 9IC6-� r. <br /> 2 / oll - 121 <br /> � s��rf����s2� �.Y ser v ice I -E-�n� <br /> Item/LocationTemperature Item Location I Temperature <br /> -21 <br /> Food`5afety Certification ( =Facility fiat water Temperature Warewashing <br /> Name: \ \\ .Hand Sink: i rl y o f Chlorine: ,� Ppm Heat: -- 'F <br /> Exp.Date: v 2 arewashin Sink: 1 _ of Quat.Amm.: PPM Other: of <br /> A 0 <br /> Received By/Tit <br /> EH Specialist: C on : <br /> --.....----_ DC7 <br /> Time in: t�� so Time Out: 1 3� Pag of Z <br /> EHD 16-24 (2° pg) 4/3113 J FOOD PROGRAM OR CONTINUATION <br />