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SAN JOAQUIN COUNTY <br /> �. oG <br /> ENVIRONMENTAL HEALTH DEPARTM NT <br /> 304 East Weber Avenue, 3`d Floor, Stockton, CA 95202-2708 <br /> Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd <br /> VECTOR CONTROL INSPECTION FORM <br /> POULTRY RANCH DBA d INSPE TION DATE <br /> Structure Operation Water Well /,Q (/ <br /> ❑ 1. ell C struction PREMISE ADDRESS ® REINSPECTION DATE <br /> ❑ ❑ 2. Cross-Connection t <br /> Structure Operation Manure Management OWNER/OPERPHONE �] <br /> E] 3. Spreading and Disking 1 RAerr' <br /> 4ft <br /> ❑ 4. Concrete Tanks PECTION TYPE PROGRAM ELEMENT CORD ID <br /> ❑ ❑ ingOle 0_ <br /> ❑ ❑ 6. Composting The items below represent tode violations and must be corrected: <br /> Structure Operation Bird Disposal <br /> ❑ ❑ 7. Burying with 2"of Cover <br /> ❑ 8. Approved Concrete Tank �s �s /, <br /> Elova m Premises ' ® w' ®1!1 aV <br /> Structure Operation Vector Control <br /> ❑ ❑ 10. Domestic Fl r- ro 'anookis <br /> 111 1. Fannia Fl <br /> ❑ 12, Larvae ° Elies <br /> 11 Al 13. Pupae e > <br /> 11 14. Adult Q tja±4 <br /> bO 6n <br /> ❑ ❑ 15. Light Population r � <br /> ❑ 16. Moderate Population <br /> ❑ ❑ 17. Heaving/ at ulation '{'u PIA' ' I�cr �®U-� j <br /> Structure Operation Feeding/Water f� KI ,mss 1. �' aLAA <br /> ❑ ❑ 18. Water Troughs <br /> ❑ r Bowls <br /> ❑ 20. Food Storage t <br /> Structure Operation Houses <br /> ❑ 21. Floors ,�+ <br /> ❑ 22. Walls/Ceilings s f <br /> ❑ ❑ 23. Cleaning Frequency <br /> KENNEL -to I 0-PIC1,�-M . <br /> Structure Operation Water Well > <br /> 11 El 1. Well Construction o 4� <br /> 11 0 2. Cross Connection <br /> Structure Operation Floors <br /> ❑ ❑ 3. Properly Graded to <br /> ❑ ❑ 4. Drain <br /> ❑ El 5. Smooth/Cleanable <br /> ❑ El 6. Covin <br /> ❑ ❑ 7. Cleaning Frequency ; <br /> Structure Operation Walls 1 <br /> ❑ ❑ 8. Smooth/Cleanable <br /> ❑ 0 9. Cleaning Frequency <br /> Structure Operation Cages <br /> ❑ El 10. Condition <br /> ❑ ❑ 11. Sanitation <br /> Structure Operation Food <br /> ❑ El 12. Storage <br /> ❑ ❑ 13. Insect/Vermin <br /> Structure Operation Animal Disposal <br /> ❑ ❑ 14. Removal from Premises <br /> ❑ ❑ 15. Other <br /> Structure Operation Sewage Disposal <br /> ❑ 0 16. Septic System a <br /> ❑ 17. Sewer <br /> !A� <br /> Structure Operation Rabies Vaccination RECEIVED B < INSPECT® <br /> ❑ ❑ 18. Certificate on Premises <br /> EHD 40-06 6/30/2005 Page Of <br />