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P° t" SAN JOAQUIN COUNTY <br /> � ffzt. 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 INSPECTION DATE <br /> Structure Operation Water Well `-ay Iv <br /> ❑ ❑ 1. Well Construction PREMISE ADDRESS ,� REINSPECTION DAATTE� <br /> 1:1 El 2. Cross-Connection OIQ l_>^ �/� F-C l -7')7-061 <br /> Structure Operation Manure Management OWNER/OPERATOR tECORD <br /> NE /� <br /> ❑ El3. Spreading and Disking -Z 79 9 ���LS <br /> 1:1 [:] 4. Concrete Tanks INSPECTION TYPE / PROGRAM ELEMENT ID h [ <br /> � <br /> El 5. Lagooning �"- ffip / �, q-0L+T� dstV I '� <br /> 11 El6. Composting The Items below represent code violations and must be corrected: <br /> Structure Operation Bird Disposal l <br /> ❑ ❑ 7. Burying with 2"of Cover h 8V 2�' �� � 0- V � ��� <br /> ❑ ❑ 8. Approved Concrete Tank t I <br /> 11 El 9. Removal from Premises tM t O®ryl"0 er6,/},PV7 tlek _C je " I► Ad <br /> Structure Operation Vector Control ( .y!V�, -�L) <br /> 11 E] 10. Domestic Fl t^"eq access on ct�`• hdlnS 1 `^-km, <br /> ❑ ❑ It. Fannia Fly /�� �^t r <br /> El El12. Larvae V66fT 11 I Tr/V I) Ell�IayF DBST�t�CTiaN <br /> 11 El 13. Pupae <br /> ❑ ❑ 14. Adult I N TZ) AIOW YV P01%) A,( CE-SS AY <br /> ❑ ❑ 15. Light Population <br /> ❑ ❑ 16. Moderate Population <br /> ❑ ❑ 17. Heavy Population <br /> Structure Operation Feeding/Water <br /> ❑ ❑ 18. Water Troughs <br /> El El 19. Cups or Bowls ✓t ack yea fen--7 <br /> 0)i is <br /> 11 ❑ 20. Food Storage <br /> Structure Operation Houses w1an k � a.)d-S FC)y/ httgeSa <br /> Wn i /Aah <br /> - <br /> ❑ ❑ 21. Floors f <br /> 11 22. Walls/Ceilings l✓� Plat T C4kffe_ j.U /-Mlf CiDeS not <br /> ❑ ❑ 23. Cleaning Frequency , }, <br /> KENNEL tSS �X(Sllr <br /> Structure Operation Water Well <br /> ❑ ❑ 1. Well Construction 4 n,�C nAtk MAPA6EAEN_ PLAN U <br /> ❑ ❑ 2. Cross Connection J <br /> Structure Operation Floors C /V_ !V f%IT 7O IN CUIPE ORCK MEAT OP <br /> ❑ ❑ 3. Properly Graded to <br /> ❑ ❑ 4. DrainE-P-A-110M " fW(P <br /> ❑ ❑ 5. Smooth/Cleanable <br /> ❑ ❑ 6. Covin <br /> ❑ ❑ 7. Cleaning Frequency -1 t� <br /> Structure Operation Walls ,♦ �� VNj/I i" a <br /> /��7� p o J I{� s <br /> ❑ ❑ 8. Smooth/Cleanable ,c <br /> El El 9. CleaningFrequency i S 61 1 le jo prDW44 owner a S 3'." <br /> Structure Operation Cages <br /> El 10. Condition Ail Wok's <br /> ❑ ❑ 11. Sanitation o�A �ii/_ ^ /y Cy{. �� <br /> Structure Operation Food �S 0 e, U 111 In }+_ �. I-J e- 1'a 9 <br /> ❑ ❑ 12. Storage <br /> ❑ ❑ 13. Insect/Vermin �b ' <br /> Structure Operation Animal Disposal <br /> ❑ ❑ 14. Removal from Premises <br /> ❑ ❑ 15. Other <br /> Structure Operation Sewage Disposal <br /> ❑ ❑ 16. Septic System <br /> ❑ ❑ 17. Sewer <br /> Structure operation Rabies Vaccination RECEIVED BY SPECTOIt <br /> r <br /> ❑ ❑ 18. Certificate on Premises 1`,'N&'- <br /> EHD 40-06 6/30/2005 Page aof <br />