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oAa�ty c <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> :=. 1868 East Hazelton Avenue, Stockton, California 95205-6232 <br /> . cc. Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd <br /> q<iFORN <br /> VECTOR CONTROL INSPECTION FORM <br /> DBA It IN SP iO�N � <br /> Structure Operation Water Well <br /> ❑ ❑ 1. Well Construction PREMISE ADDRESS RE-INSPECTION DATE <br /> ❑ ❑ 2. Cross-Connection 316 / <br /> Structure Operation Manure Mana em t OWIJERIOPERATOR P/ ONE <br /> ❑ ❑ 3. Spreading and king f l d 3 3 ,t- 7.� <br /> ❑ ❑ 4. Concrete Tanyg INSPE TION TYPE PROGRAM ELEMENT REC DID _ <br /> E] ❑ 5. Lagooning .l -3 <br /> ❑ ❑ 6. Compos' g The items below represent code violations and must be corrected: <br /> Structure Operation Bird D1960sal <br /> ❑ ❑ 7. Bu nq with 2"of Cover22t41 <br /> ❑ ❑ 8. Aroved Concrete Tank , <br /> ❑ ❑ 9. emoval from Premises <br /> Structure Operation actor Control <br /> ❑ ❑ 1 10. Domestic FI <br /> 11. Fannia FI <br /> ❑ ❑ 12. Larvae <br /> ❑ EY 13. Pupae <br /> ❑ ZI 14. Adult <br /> ❑ ❑ 15. Li ht Population <br /> ❑ ❑ 16. Moderate Population <br /> ❑ ❑ 17. Heavy Population Lr .� <br /> Structure Operation Feedingmater <br /> ❑ ❑ 18. Water Troughs <br /> Ey ❑ 19. Cups or Bowls v- <br /> 20. Food Storage <br /> cture Operation Houses <br /> ❑ ❑ 21. Floors <br /> ❑ ❑ 22. Walls/Ceilings F <br /> ❑ ❑ 1 23. Cleaning Frequency <br /> Structure Operaticrq Water We <br /> ❑ ❑ ell Construction <br /> 2. Cross Connection rye, <br /> Structure operati of 0 4 ® '® <br /> -1-15r-opedy Graded to Sewer <br /> ❑ ❑ >4. Drain <br /> ❑ ❑ . Smooth/Cleanable P <br /> 6. Covin <br /> El 1-1 7_QaWing Frequency <br /> Structure Operatio Wa <br /> ❑ ❑ 8. Smooth/Cleanable <br /> ❑ ❑ 9. Cleaning Frequency <br /> Structure Operation< ages <br /> ❑ ❑ 0. Condition <br /> 1. Sanitation <br /> Structure Operation <br /> ❑ ❑ Storage <br /> El Insect/Vermin <br /> Structure Operation Animal Disposal <br /> ❑ ❑ 14. Removal from Premises <br /> ❑ ❑ er <br /> Structure operati wage Dis <br /> ❑ ❑ stem <br /> ❑ ❑ <br /> Structure Operatio Rabies Vaccination RECEIV BYINSP T R <br /> ❑ ❑ 18. Certificate on Premises <br /> VECTOR CONTROL INSPECTION FORM <br /> EHD 40-06 4/6/12 Page of <br />