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oea"IN c*SAN JOAQUIN COUNTY <br />a Za ENVIRONMENTAL HEALTH DEPARTMENT <br />N.. X <br />600 East Main Street Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 464-0138 Web: www.sjgov.org/ehd <br />�IFOR <br />VECTOR CONTROL INSPECTION FORM <br />Structure <br />Operation <br />DBAINSPECTION <br />DATE <br />❑ <br />❑ <br />1. Well Construction <br />PREMISE ADDRESS <br />J000.3 <br />RE-IIII&ECTION DATE <br />❑ ❑ 2. Cross -Connection <br />Structure <br />operation <br />Manure Management <br />OWNER/OPERATOR <br />PHONE <br />t' S " o6 -z <br />❑ ❑ 3. Spreading and Disking <br />❑ <br />❑ <br />4. Concrete Tanks <br />INSP CTION TYPE <br />PROGRAM ELEMENT <br />V 3- <br />RECORD ID <br />❑ ❑ 5. Lagooning <br />0 <br />❑ <br />6. composting <br />The items below represent code violations and must be corrected: <br />Structure <br />Operation <br />Bird Disposal <br />❑ ❑ 7. Burying with 2" of Cover <br />❑ <br />❑ <br />8. Approved Concrete Tank <br />kVk r 14 0 <br />❑ ❑ 9. Removal from Premises <br />Structure <br />Operation <br />Vector Control <br />❑ ❑ 10. Domestic FI <br />11. Fannia FI <br />®� <br />hrP4 J®/z <br />❑ ❑ 12. Larvae <br />❑ <br />❑ <br />13. Pupae <br />T r <br />❑ ❑ 14. Adult <br />❑ <br />❑ <br />15. Light Population <br />d <br />i c- <br />❑ ❑ 16. Moderate Po ulation <br />❑ <br />❑ <br />17. Heavy Population <br />t` <br />Structure Operation Feeding/Water <br />❑ <br />❑ <br />18. Water Troughs <br />❑ ❑ 19. Cups or Bowls <br />20. Food Storage <br />6 <br />Structure Operation Houses14er` <br />❑ <br />El <br />21. Floors <br />I` . <br />❑ ❑ 22. Walls/Ceilings <br />❑ <br />❑ <br />23. Cleaning Frequency <br />Structure <br />Operation <br />Water Well <br />❑ K ❑ 1. Well Construction <br />2. Cross Connection <br />Structure Operation Floors <br />❑ <br />❑ <br />3. Proed Graded to Sewer <br />❑ ❑ 4. Drain <br />❑ <br />❑ <br />5. Smooth/Cleanable <br />d <br />11 ❑ 6. Covin <br />7. Cleaning Frequency <br />, <br />Structure Operation Walls <br />❑ <br />J4. ❑ <br />8. Smooth/Cleanable <br />❑ ❑ 9. Cleaning Frequency <br />Structure <br />Operation <br />Cages <br />❑ ❑ 10. Condition <br />11. Sanitation <br />Structure Operation Food <br />❑ <br />❑ <br />1 12. Storage <br />13. Insect/Vermin <br />Structure <br />Operation <br />Animal Disposal <br />❑ ❑ 14. Removal from Premises <br />❑ <br />❑ <br />15. Other <br />Structure I operation Sewage Disposal <br />❑ <br />oiL ❑ <br />16. Septic System <br />❑ ❑ 17. Sewer <br />Structure <br />Operation <br />Rabies VaccinationD <br />t3Y <br />SPECTOR <br />r <br />11 CIL 1:118. Certificate on Premises <br />VECTOR CONTROL INSPECTION FORM <br />EHD 40-06 12/04/08 <br />Page of <br />