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SAN JOAQUIN COU. r <br />• o¢G'FAG � <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />gid...•,..,..:;P Telephone: (209) 468-3420 Fax: (209) 464-0138 Web: www.sigov.org/ehd <br />�1FOR� <br />FOOD PROGRAM OFFICIAL INSPECTION REPORT <br />Name of Facility:QlUM-R/rG <br />U.CC -0 5K S <br />Date: DI 23/ <br />Address: <br />"A (, I r4d City: <br />1'I— Zip Code: A5 / <br />Owner/Operator: <br />VII-InCA a1 fo <br />Telephone: <br />Program Element:1�o <br />Program Record: � ()I�N "�rY <br />V—1Inspection Type: _ .M -b t4 j, <br />8180 Posted Yes No Permit Posted Yes No <br />Re -Inspection on or After: <br />OBSERVATIONS AND CORRECTIVE ACTIONS <br />is &oli C"\CA Y G0(- <br />r -+a - eq <br />v< <br />mk-s 2 S in 1 c <br />2ul <br />;9;V cx(-•e <br />- <br />Itemll-ocation i Temperature <br />-_-_ p <br />_ _ <br />I <br />Item f Location Temperature <br />Food <br />Name: <br />Safety Certification ` <br />Facility Hot Water Temperature <br />Hand Sink: �F <br />Warewashing <br />Chlorine: ppm <br />Heat `.F <br />Exp. Date: <br />rewashing Sink: <br />"F <br />Ouat. Amm.: ppm <br />then. _ F <br />Received By / Title: <br />EH Specialist: <br />64�Phone: <br />Time in: 06 <br />Time Out: `^ Pageof <br />EHD 16-24 (2 -pg) 4/3113 FOOD PROGRAM OIR CONTINUATION <br />