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oP°H'"•. SAN JOAQUIN COUNTY <br />_ ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />•'�4<ipdV'ei+�p • Telephone: (209) 468-3420 Fax: (209) 464-0138 Web: www.s'aov.ora/ehd <br />FOOD PROGRAM OFFICIAL INSPECTION REPORT <br />Name of Facility: <br />_ <br />Date: <br />Z ` <br />ddress:- <br />f� City: <br />LV <br />Zip Code: <br />Owner/Operator: <br />Telephone: <br />Program Element: <br />I /� ? 6' <br />-Prhdram Re rd: /' <br />— Inspection Type: <br />/ V! <br />SB180 Posted Yes <br />No <br />Permit Posted Yes No <br />Re -Inspection on or After: <br />OSE . AIQ SAND CORRECTIVE ACTIONS <br />Q,1 <br />1D1 <br />63 <br />r <br />412 <br />C . <br />of <br />f I <br />I <br />re <br />Q <br />ItemiL .. <br />- Tempera Un-` <br />.... -- - ' hocatl...r" -� <br />Footl Safety Certification Facility Hot Water Temperature <br />Name: is Hand Sink: l `- <br />(J <br />= Warew" <br />of Chlorine: � ppm Heat: <br />=F <br />Exp. Date: <br />23 <br />arewashing Sink: <br />of Quat. Amm.: ppm ther: <br />=F <br />Received By/ Title: <br />O <br />EH Specialist: <br />Phone: <br />^ <br />Time In:y <br />D <br />Time Out: tr <br />Page of <br />EHD 16-24 (2n Pg) 4013 FOOD PROGRAM OIR CONTINUATION <br />