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SAN JOAQUIN COUNTY <br /> A <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, California 95205-6232 <br /> • •.. ;P• <br /> Telephone:(209) 468-3420 Fax:(209) 464-0138 Web:www.sjgov.org/ehd <br /> ���FORN ® p� <br /> VECTOR CONTINSPECTION FORM <br /> ijIffoluffilln= DBAR INSPECTION DATE <br /> Structure Operation <br /> ❑ ❑ 1. Well Construction PREMISE ADDRESS L PECTION DATE <br /> ❑ ❑ 2. Cross-Connection <br /> Structure Operation Manure management O NER/OPERATOR PHONE <br /> ❑ ❑ 3. Spreading and Diskingjr <br /> 4.6 <br /> ❑ ❑ 4. Concrete Tanks INSPECTION TYPE PROGRAM ELEMENT RECORD ID <br /> ❑ ❑ 5. Lagooning <br /> ❑ ❑ 6. Composting The items below represent code violations and must be corrected: <br /> Structure Operation Bird Disposal <br /> ❑ ❑ 7. Burying with 2°of Cover <br /> ❑ ❑ 1 8. Approved Concrete Tank _ <br /> ❑ ❑ 9. Removal from Premises ii, 11 lkr, t <br /> Structure Operation Vector Control <br /> ❑ ❑ 10. Domestic Fly ck2!2 <br /> 11. Fannia FI <br /> ❑ ❑ 12. Larvae <br /> ❑ ❑ 1 13. Pupae <br /> ❑ ❑ 14. Adult <br /> ❑ ❑ 15. Light Population t <br /> ❑ ❑ 16. Moderate Population ,( <br /> ❑ ❑ 17. Heavy Population <br /> Structure Operation FeedinglWater <br /> ❑ ❑ 18. Water Troughs <br /> ❑ KOtion <br /> 19. Cups or Bowls <br /> El 20. Food Storage <br /> Structur ('louses <br /> ❑ 21. Floors <br /> ❑ 22. Walls/Ceilings <br /> ❑ ❑ 23. Cleaning Fre uenc <br /> vlza'4 lam <br /> Structure Operation water well <br /> ❑ ❑ 1. Well Construction o <br /> nn A <br /> El EI 2. Cross Connection <br /> Structure Operation Floors <br /> 3. Prooedv Graded to Sewer <br /> ❑ ❑ 4. Drain <br /> ❑ ❑ 5. Smooth/Cleanable <br /> 6. Covin 1 _ <br /> El Ej 7. Cleaning Frequency <br /> Structure Operation Walls <br /> ❑ ❑ 8. Smooth/Cleanable <br /> ❑ ❑ 9. Cleaning Frequency <br /> Structure Operation Cages P <br /> ❑ ❑ 10. Condition <br /> 11. Sanitation <br /> Structure Operation Food ✓ <br /> ❑ ❑ 12. Storage <br /> 13. Insect/Vermin <br /> Structure Operation Animal Disposal <br /> ❑ ❑ 14. Removal from Premises Lau ketLr <br /> ❑ ❑ 15. Other <br /> Structure Operation Sewage Disposal <br /> ❑ ❑ 16. Septic System <br /> ❑ ❑ 17. Sewer <br /> Structure Operation Rabies Vaccination RECEIV B INSP CT R 1 <br /> ❑ ❑ 18. Certificate on Premises <br /> VECTOR CONTROL INSPECTION FORM <br /> EHD 40-06 4/6/12 <br /> Page_of <br />