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OQ;QuIN•• C <br />).• �EEr.,pG <br />Q• 'yam <br />411 W x <br />�/PORN <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax. (209) 464-0138 Web: www.sjgov.org/ehd <br />VECTOR CONTROL INSPECTION FORM <br />Structure <br />Operation <br />Water WellC <br />DBA -- <br />l� I G" k Qti i l CA <br />INS PEC ION D TE <br />/ <br />❑ <br />❑ <br />1. Well Constr ction <br />PREMISE ADDRESS <br />RE -INSPECTION DATE <br />❑ ❑ 2. Cross -Con ection <br />Structure <br />Operation <br />Manure M#hagement <br />OWNER/OPERATORn <br />,% � (�/' Tr. It WENS r�"�6 <br />E L/C <br />9-r� / / <br />3. Spreadi g and Disking <br />El[1� <br />❑ <br />❑ <br />4. Concr a Tanks <br />INSPECTI1 <br />,, �)PE y1 <br />% t,r Li <br />PROGRAM <br />t ELEMENT <br />-/ 5_0 <br />RECORD Q � <br />PA U � 00 Jo' <br />❑ ❑ 5. Lago ning <br />❑ <br />❑ <br />6. Co posting <br />The items below represent code violations and must be corrected: <br />Structure <br />Operation <br />Bir isposal <br />❑ ❑ 7. jurying with 2" of Cover <br />❑ <br />❑ <br />8/Approved Concrete Tank <br />�, <br />f i'j s C-1 C- S L no �� S <br />El 11 Removal from Premises <br />Structure <br />Operation <br />ftector Control <br />a <br />❑ ❑ 10. Domestic FI <br />❑ <br />11. Fannia FI <br />❑ 12. Larvae <br />❑ <br />13. Pupae <br />J�'� t <br />a ro -a Er % l� <br />1314. Adult <br />❑❑ <br />15. Light Population <br />El❑ 16. Moderate Po ulation <br />11❑ <br />17. HeavyPopulation <br />2 • �� (�C/� �'' v vl �'t! -� <br />Structure Operation FeedingMater <br />❑ <br />❑ <br />18. Water Troughs <br />a <br />❑ ❑ 19. Cups or Bowls <br />❑ <br />20. Food Storage <br />St lure operation Houses <br />❑ <br />21. Floors <br />�+ G `-�/�N t.G� J ar <br />❑ ❑ 22. Walls/Ceilings <br />❑ <br />❑ <br />23. Cleanino Fre uenc <br />oO <br />Structure <br />operation/Water <br />ell <br />❑ ❑ 1. W onstruction <br />❑ <br />ross Connection <br />',, <br />t �/Vl kead )�& i ,m YC c ? <br />(� <br />Structure Operatio Floor <br />E]3. <br />Pro dy Graded to Sewer <br />❑4. rain <br />❑ <br />❑ <br />5. SmoothlCl nable <br />�/j �� L_ % � ; � 4 <br />a 'm/� T q <br />1:1 El 6. Covin <br />❑ <br />❑ <br />kffi-doninq Frequency <br />y-V Y { <br />Structure Operation Walls <br />❑ <br />0 <br />❑ <br />Doth/Cleanable <br />❑ ❑ 9 ­ Cleaning Frequency <br />Structure <br />Operation <br />ag S <br />❑ ❑ 10. ondition <br />❑ <br />Sanitation <br />Structure Operation Food <br />11 ft <br />❑ <br />12. Stprage <br />El Insect/Vermin <br />Structure <br />Operation <br />Animal Disposal <br />❑ ❑ 14. Removal from Premises <br />❑ <br />❑ <br />r <br />Structure Operation SeW Disposal <br />❑ <br />❑ <br />1<,-,e ti stem <br />Q4u '— <br />❑ ❑ <br />Structure <br />Aeration <br />R fes V ccination <br />EIVED BY <br />ul,- <br />INSP <br />❑ ❑ 18. Certificate on Premises <br />VECTOR 12/0L INSPECTION FORM Y <br />EHD 40-066 12/04/08 /' ,/ <br />✓ Page I of _ <br />