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SAN JOAQUIN COUNT Y <br /> T ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> !� Telephone: (209)468-3420 Fax: (209)464-0138 Web:www.smgov,orq/ehd <br /> 4iI�a.AN <br /> FOOD PROGRAM OFFICIAL INSPECTION REPORT <br /> Name of Facility: Date: 1 ` z` Z Z <br /> Address: �� City: Zip Code: <br /> Owner/Operator: Telephone: <br /> Program Element: Program Record: I Inspection Type: <br /> SB180 Posted Yes `JVNo Permit Posted Yes ❑ No Re-Inspection on or After: <br /> ABSERVATIONS AND CORRECTIVE ACTIONS ar' <br /> S <br /> Ck <br /> O - , <br /> itemlLocation Temperature 1temY t'ocation Temperature Item 1 Location Temperature <br /> i.... ... <br /> Food_ Safety Certificatiori Facility Hot.Water Temperature - .- Warewashmg""'' 7 <br /> Name: Hand Sink: of ('Chlorine: ppm Heat: -F <br /> Exp.Dat Warewashing Sink: of Quat.Amm.: ppm her: "F <br /> Received By I Title: .L r G1 �j7V <br /> EH Specialist: _ Phone: <br /> Time in: Time Out: V Page-t, <br /> Ll <br /> EHD 16.24 (214 pg) 0112 FOOD PROGRAM OIR CONTINUATION <br />