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SAN JOAQUIN COUt <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209) 468-3420 Fax:(209) 464-0138 Web:www.sipov.org/ehd <br /> ��FOR <br /> FOOD PROGRAM OFFICIAL INSPECTION REPORT <br /> Name of Facility: 21:11 V I Date: 1 _ ( S — I <br /> Address: -+5 City: Zip Code: C` 2� z <br /> Owner/Operator:. 1 Telephone: _b9 _1 v� -7Program Element: b` Program Record: S Z Inspection Type: <br /> b i <br /> SB180 Posted es No Permit Posted i Yes _I No Re-Inspection on or After: <br /> OBSERVATIONS AND CORRECTIVE ACTIONS <br /> Item/Location Temperature Item/Location Temperature <br /> Food Safety Certification Facility Hot Water Temperatur Warewashing <br /> Name: Hand Sink: F Chlorine: PPM Heat: °F <br /> Exp.Date: Warewashing Sink: 'F Ouat.Amm.: PPM Other: 'F <br /> Received By/Title: <br /> EH Specialist: Phone: 14 _ 0-2 <br /> Time in: 15C) Time Out: `� J Page of <br /> EHD 16-24 (2n1 pg) 4/3/13 FOOD PROGRAM OIR CONTINUATION <br />