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SAN eTOAQU IN COUNTY <br /> Q ENVIRONMENTAL HEALTH DEPARTME T <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202-2708 <br /> Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd <br /> �FpR <br /> VECTOR CONTROL INSPECTION FORM <br /> POULTRY RANCH DBA INSPECTIO DATE <br /> Structure Operation Water Well - 1n �l VM- C._ <br /> ❑ ❑ 1' Well Construction PR MISEAMESS REINS ECTI N DATE <br /> ❑ ❑ 2. Cross-Connection Z I,>0 a y a,,� a14 5 <br /> Structure Operation Manure Management OWNER/OPERATOR PHONE <br /> ❑ ❑ 3. Spreading and Disking A t V\ r CA\�' <br /> ❑ 4. Concrete Tanks INSPECTION PILA PROGRAM ELEMENT RECORD ID <br /> 10 ❑ 5. Lagooning -2- Q tb <br /> ❑ ❑ 6. Composting The items below represent code violations and must be tiph. <br /> Structure Operation Bird Disposal <br /> ❑ ❑ 7. Burying with Y'of Cover y,�-t\A-(_ k "J <br /> ❑ ❑ 8. Approved Concrete Tank qq <br /> ❑ ❑ 9. Removal from Premises .,�VlL'l-v b1-v�ti� <br /> Structure Operation Vector Control L <br /> ❑ ❑ 10. Domestic Fl `A- ti 11 <br /> ❑ ❑ 11. Fannia Fly It <br /> ❑ ❑ 12. Larvae DD L <br /> ❑ ❑ 13. Pupae <br /> ❑ ❑ 14. Adult a t DWv -(�� l.V Ot:4 i Lu <br /> ❑ ❑ 15. Li ht Population <br /> ❑ ❑ 16. Moderate Population - ltn� tAA .mow - <br /> ❑ ❑ 17. Heavy Po ulation <br /> Structure Operation Feeding/Water Ql4'c <br /> ❑ ❑ 18. Water Troughs -, <br /> ❑ ❑ 19. Cups or Bowls L Vv\,L <br /> ❑ ❑ 20. Food Storage _r` <br /> Structure Operation Houses •�\ O �- \lU <br /> ❑ ❑ 21. Floors <br /> ❑ ❑ 1 22. Walls/Ceilings L 1 <br /> ❑ ❑ 1 23. Cleaning Frequency _-I _ , - <br /> KENNEL V\I , / 0.t <br /> Structure Operation Water Well 1 <br /> ❑ ❑ 1. Well Construction fd �•�.� �vN'�tVlav \ �� <br /> ❑ ❑ 2. Cross Connection ` ,-, <br /> Structure Operation Floors y. ^�Gl -e,- <br /> ❑ ❑ 3. Properly Graded to <br /> ❑ ❑ 4. Drain <br /> ❑ ❑ 5. Smooth/Cleanable <br /> ❑ ❑ 6. Covin L O �OG ( V% L <br /> ❑ ❑ 7. Cleaning Frequency \ <br /> Structure Operation Walls �9'>V- ��•.1� <br /> ❑ ❑ 8. Smooth/Cleanable <br /> ❑ ❑ 9. Cleaning Frequency <br /> Structure Operation Cages < <br /> ❑ ❑ 10. Condition G <br /> ❑ ❑ 11. Sanitation y <br /> Structure OperationFood A f; l <br /> ❑ ❑ 12. Storage <br /> ❑ ❑ 13. Insect/Vermin to<7 <br /> Structure Operation Animal Disposal \ <br /> ❑ ❑ 14. Removal from Premises L c� a-/�(_ v-C <br /> ❑ ❑ 15. Other <br /> Structure Operation Sewage Disposal <br /> ❑ ❑ 16. Septic S stem <br /> ❑ ❑ 17. Sewer <br /> Structure Operation Rabies Vaccination RECEIVED 8 I PECTOR <br /> ❑ ❑ 18. Certificate on Premises L <br /> EHD 40-06 6/30/2005 <br /> �5�_-�`a�y� Page_j of <br />