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' PpUIIy Q• a N• < �g F:0R�i SAN JOA UIN COUNTY ENV IRONMENTAL HEALTH DEPARTM,..... 304 East Weber Avenue, 3`d Floor, Stockton, CA 95202-2708 Telephone: (209) 468-3420 Fax: (209) 464-0138 Web: www.sjgov.org/ehd VECTOR CONTROL INSPECTION FORM Structure POULTRY RANCH DBA a �� INSPEC NDAT -Z/2 Structure Operation Water Weil 8. Approved Concrete Tank ❑ ❑ ❑ 1. Well Construction PREMISE ADDRESS� REIN P TIO ATE 11❑ 10. Domestic Fl 2. Cross -Connection VJM7 7'°'�� ❑ Structure Operation Manure Management OWNERIOPE TOR 13. Pupae P ❑ ❑ 3. Spreading and Disking (e - 15. Light Population ❑ l0] ❑ ❑ 4. Concrete Tanks INSPECTION TYPE PROGRAM ELEMENT RECORD ID ❑ ❑ 5. Lagooning 'i�1� n 1 n 1 6. Comnostine The -FPFH.% helow represent code violations and must be corrected: Structure Operation Bird Disposal ❑ ❑ 7. Burying with 2" of Cover ❑ ❑ 8. Approved Concrete Tank ❑ ❑ 9. Removal from Premises Structure Operation Vector Control ❑ ❑ 10. Domestic Fl ❑ ❑ 11. Fannia FI ❑ ❑ 12. Larvae ❑ ❑ . 13. Pupae ❑ ❑ 14. Adult ❑ ❑ 15. Light Population ❑ ❑ 16. Moderate Population ❑ 1 ❑ 1 17. Heavy Population Structure Operation Feeding/Wa ❑ ❑ 18. Water T ❑ ❑ 19. Cups or Structure I Operation I Houses ❑ I ❑ 1 21. Floors ❑ ❑ 1 23. Cleaning Fouen ❑ KENNEL_ Structure Operation Water Well ❑ ❑ 1. Well Construction ❑ ❑ 2. Cross Connection Structure Operation Floors ❑ ❑ 3. Properly Graded to ❑ ❑ 4. Drain ❑ ❑ 5. Smooth/Cleanable ❑ ❑ 6. Covin ❑ ❑ 7. Cleaning Frequenc Structure Operation Walls ❑ ❑ 8. Smooth/Cleanable ❑ I ❑ 1 9. Cleaning Frequenc Structure Operation Cages ❑ ❑ 10. Condition ❑ ❑ 11. Sanitation Structure Operation Food ❑ ❑ 12. Storage ❑ 1 ❑ 1 13. Insect/Vermin Structure Operation Animal Disposal ❑ ❑ 14. Removal from Premises ❑ ❑ 15. Other Structure I Operation U u 1 16. Septic S stem ❑ ❑ 17. Sewer Structure Operation Rabies Vaccination ❑ ❑ 18. Certificate on Pi BY t A EHD 40-06 6/30/2005 ! Page - of