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oe4 '"• SAN JOAQUIN COON. <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />•.C4CIFOF��P • Telephone: (209) 468-3420 Fax: (209) 464-0138 Web: www.sioov.org/ehd <br />FOOD PROGRAM OFFICIAL INSPECTION REPORT <br />Name of Facility: <br />/-..oma <br />Date: 0 <br />— <br />Address: <br />c <br />City: <br />Zip Code: 9 <br />2— <br />Owner/Operator: <br />Telephone: 20 <br />S <br />Program Element: <br />Program Record: 00 / <br />[ <br />Inspection Type: <br />58180 Posted Yes <br />No <br />Permit Posted Yes No <br />Re -Inspection on or After: <br />OBSERVATIONS AND CORRECTIVE ACTIONS <br />r <br />J <br />z <br />AAr <br />r <br />/ <br />ctJQ t. f <br />Item/Location <br />Temperature <br />Item / Location <br />Temperature <br />Food Safety Certification Facility Hot Water Temperature <br />` Warewashing`;, <br />Name:Hand <br />Sink: <br />of Chlorine: ppm <br />He <br />aF <br />Exp. Date: <br />arewashing Sink: <br />=F Quat. Amm.: PPM <br />ther: <br />eF <br />Received By/ Title: <br />EH Specialist: <br />Ang 144 <br />6 <br />Phone:104 <br />ime in: <br />r r <br />Time Out: <br />Page of <br />EH016-24 (2 -Pg) 4013 FWD rnuunnm um wn inurenvn <br />