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SAN JOAQUIN COUN& <br /> ENVIRONMENTAL HEALTH DE RTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209) 468-3420 Fax:(209) 464-0138 Web:www.sigov.org/ehd <br /> 4�FbA� <br /> FOOD PROGRAM OFFICIAL INSPECTION REPORT <br /> Name of Facility: �� �� Date: \ t 0 I <br /> Address: () \14 <br /> V•r„11 vv City: t Zip Code: <br /> Owner/Operator: V Telephone:�l <br /> Program Eleme Recor � Inspection Type: <br /> SB180 Posted Yes No Permit Posted Yes No <br /> ✓✓✓✓ Re-Inspection on or After: <br /> ?� �- lOBSERUATIONS�AND�CORREGTIVE ACTIONS -.�h� y <br /> 1) Qi-4c. u n i n Or S 1 <br /> S , <br /> +y. -`'� tL" c -xoe----.-ice 'tri w > �T+�*. g.a�a�aY <br /> VO CertificahomT; -,�F�acNty7Ho_tiWatexTemperature�!,_�--a ��+� '�-c ;�Wa�ewastimg�,�; � <br /> Name: and Sink: .F hlorine:-.,, PPM Heat: .F <br /> Exp.Date: arewashing Sink: .F r <br /> uat.Amm.: Ppm ther: .F <br /> Received By/Title: V b G A . <br /> EH Specialist: Phone: _ <br /> Time In: 64 TZ3 <br /> q: ,e Time Out: Pagel of <br /> EHD 1624 (2-Pg)4013 FOOD PROGRAM OIR CONTINUATION <br />