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°4"�" SAN JOAQUIN COI, I <br /> Y �s •.OG <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> _ 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209) 468-3420 Fax: (209) 464-0138 Web:www.sigov.org/ehd <br /> a�iFo.Ra <br /> FOOD PROGRAM OFFICIAL INSPECTION REPORT <br /> Name of Facility: ul1�AQ jOXW_ Date: Z <br /> Address: 2� 2 I pond C) City: c � Zip Code: 2 <br /> Owner/Operator: Telephone: <br /> Program Element: 1 Program Record: P I K/1 f_r q -4 Inspection Type: ti N Q <br /> SB180 Posted Yes No Permit Posted Yes No Re-Inspection on or After: v <br /> ORRECTIVE ACTIONS <br /> ,OBSERVATIONS.AND„C <br /> food ca/T-�fi rj mN lcm� r nod- cm QCAel <br /> �A GAq�-cain a Ccs cm S\ <br /> r <br /> Item/Location _ Temperature Item t Location Temperature <br /> —....... .� _....... -- _ _ <br /> Food Safety Certification r Facility Hot Water Temperature r Warewash ng <br /> --- I---— <br /> Name: (Hand Sink: of Chlorine: PPM Heat: of <br /> Exp.Date: !Warewashing Sink: of IQuat.Amm.: PPM (Other: of <br /> Received By/Title: <br /> E_H Specialist: Phone: (�i(� 4 rob <br /> Time in: Time Out: TJ Page11of <br /> EHD 16-24 (2n1 pg) 413113 FOOD PROGRAM OR CONTINUATION <br />