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AQu'" SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 East Hazelton Avenue, Stockton, California 95205-6232 <br />Telephone: (209) 468-3420 Fax; (209) 464-0138 Web: www.sjgov.org/ehd <br /><<F Oita <br />VECTOR CONTROL INSPECTION FORM <br />VECTOR CONTROL INSPECTION FORM <br />EHD 40-06 4/6/12 <br />Page -L of <br />DBA/tINSPECTiop <br />DATE <br />Structure <br />Operation <br />,3 Z l3 <br />❑ <br />❑ <br />1. Well Construction <br />PREMISE ADDRESS <br />RE -INSPECTION DATE <br />❑ <br />❑ <br />2. Cross-Connection:i_- <br />0 S. <br />� <br />Structure <br />Operation <br />Manure Manage t <br />OWNER/OPERATOR <br />❑ <br />❑ <br />3. Spreading and Di ing <br />�. <br />/PHONE <br />[ �') %� C9�a2 `f <br />El❑ <br />4. Concrete Tanks <br />INSPECTION TYPE <br />PROGRAM ELEMENT <br />RECORD ID <br />❑ <br />❑ <br />5. Lagooning <br />❑ <br />❑ <br />6. Composting <br />The items below represent code violations and must be corrected: <br />Structure <br />Operation <br />Bird Dlspo I <br />❑ <br />❑ <br />7. Burvinq ith 2" of Cover <br />® <br />r J <br />❑ <br />❑ <br />8. A rov d Concrete Tank <br />❑ <br />❑ <br />9. Rem al from Premises <br />m <br />Structure <br />Operation <br />V@ct Control <br />❑ <br />❑ <br />10. omestic FI <br />11. Fannia FI <br />_ a 6 <br />ke �J R <br />f^ <br />❑ <br />❑ <br />1Z Larvae <br />❑ <br />❑ <br />A3. Pupae <br />❑ <br />❑ <br />14. Adult <br />❑ <br />❑ <br />15. Light Population <br />❑ <br />❑ <br />16. Moderate Population <br />®� <br />❑ <br />17. Heavy Population <br />Structure <br />Op e tion <br />Feeding/Water <br />❑ <br />18. Water Troughs <br />, <br />P <br />❑ <br />❑ <br />19. Cups or Bowls <br />El <br />El <br />20. Food Storage <br />Structure <br />Operation <br />Houses <br />❑ <br />❑ <br />21. Floors <br />ter <br />❑ <br />22. Walls/Ceilings <br />in <br />❑ 1 <br />23. Cleanin Fre uenc <br />�. <br />Structure <br />Operation <br />IN Iffiffi <br />Water Well <br />.-- � <br />7� <br />❑ <br />❑ A <br />1. Well Construction <br />2. Cross Connection <br />Structure <br />Operation <br />Floors <br />3. Properly Graded to Sewer <br />H <br />❑ <br />❑ <br />4. Drain <br />❑ <br />❑ 1 <br />5. Smooth/Cleanable <br />❑ <br />6. Covin <br />7. Cleaning Frequency <br />Structure <br />Operation <br />Walls <br />❑ <br />❑ 1 <br />8. Smooth/Cleanable <br />❑ <br />❑ <br />9. Cleaning Frequency <br />Structure <br />Operation <br />Cages <br />❑ <br />❑ <br />10. Condition <br />El <br />11. Sanitation <br />Structure <br />Operation <br />Food <br />❑ <br />❑ <br />12. Storage <br />1:1 <br />El <br />13. insect/Vermin <br />Structure <br />Operation <br />Animal Disposal <br />❑ <br />❑ <br />14. Removal from Premises <br />❑ <br />❑ <br />5. Other <br />Structure <br />Operation <br />Sewage Disposal <br />❑ <br />❑ <br />16. Septic System <br />❑ <br />❑ <br />7. Sewer <br />Structure <br />Operation <br />Rabies Vaccination <br />RECEIVED BY <br />INSPECTOR <br />❑ <br />❑ 01-18. <br />Certificate on Premises <br />VECTOR CONTROL INSPECTION FORM <br />EHD 40-06 4/6/12 <br />Page -L of <br />