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w: <br />Zip Code: <br />Telephone: <br />Inspection Type:Program Element:Program Record: <br />Re-Inspection on or After:Permit PostedSB180 Posted <br />OBSERVATIONS AND CORRECTIVE ACTIONS <br />( <br />I <br />1^2-21 <br />W- <br />4^ <br />n <br />Item / Location <br />Chlorine:Name:°FPPm <br />Other:Warewashing Sink:Quat. Amm.:Exp. Date:PPm <br />LReceived By / Title: <br />Phone: <br />Time Out: <br />( <br />San Joaquin Coui^k <br />Environmental Health Department <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 464-0138 Web: www.siqov.org/ehd <br />2 Ax <br />Name of Facility: <br />Address: <br />Warewashing <br />Heat: <br />fig <br />°Ig Vk <br />UjglQQ <br />Owner/Operator: <br />Temperature <br />mi r <br />' 58F <br />m i r <br />Temperature <br />\ Wo l~^ <br />F <br />Facility Hot Water Temperature <br />Hand Sink: <br />°F °F <br />'bz - <br />____dQO <br />VxjcJggF Wo <br />gV'—-v G-Vj<- <br />________________________C X <br />\S^F-S <br />Yes No <br />Food Safety <br />V-A <br />9. GAV-fr <br />AGA <br />Food Program Official Inspection Report <br />1 OsAj OwW FaA-A-'H no Date: \O-~7-iH <br />Was <br />Yes No <br />\ A/x C <br />' 010 <br />' ’ Pagelot ?, <br />FOOD PROGRAM OIR CONTINUATION <br />W) qV-wV <br />__2, gW P-q .oq. <br />& "2aW fiLpW ~~T / <br />- (D ' <br />• . tore V <br />°F <br />\AI\ )(7V <br />IM <br />\ gx M \ <br />i wo. ~ ~v<b vty I WQ <br />i m i r_____ <br />W 12-SP <br />ZAVQ <br />AS W FAW <br />__________ ________ <br />p \be>F__________________VgW x <br />k Q &O H ( C \aJVF -Prgf <br />i( A < ' 1 \ W-* <br />Item/Location <br />. A> Ckydic_________ <br />QQ W qV\ Pad /) - C W <br />Certification <br />EH Specialist: .— <br />r"ne'n; FA^a <br />EHD 16-24 (2nd pg) 4/3/13