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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> to: X <br /> 1868 East Hazelton Avenue, Stockton, California 95205-6232 <br /> Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd <br /> 4rFOR <br /> VECTOR CONTROL INSPECTION FORM <br /> DBAINSPECTI NDA E <br /> Structure Operation 1111,01'3 <br /> ❑ ❑ 1. Well ConstructionPREMISE ADDRESS / RE-INSPECTION DATE <br /> El 2. Cross-Connection 31419 / /^ <br /> Structure Operation Manure Mana eme t OWNER/OPERATOR PHONE <br /> El 3. Spreading and Di ing T /R ® (200 g.31 <br /> ❑ ❑ 4. Concrete Tanks INSPECTION TYPE PROGRAM ELEMENT RECORD ID <br /> ❑ ❑ 5. Lagooning " d* <br /> ❑ ❑ 6. Compostin The items below represent code violations and must be corrected: <br /> Structure Operation Bird Dispo al <br /> ❑ ❑ 7. Bu in ith 2"of Cover ea- <br /> ❑ ❑ 8. Apprg4ed Concrete Tank <br /> ❑ ❑ 9. Re oval from Premises <br /> Structure OperationVe or Control <br /> ❑ ❑ 1 . Domestic FI <br /> El El /1. Fannia FI 3 <br /> ❑ ❑ 12. Larvae < �t <br /> ❑ ❑ 13. Pupae <br /> ❑ ❑ 14. Adult <br /> ❑ 15. Li ht Population 04) <br /> ❑ 16. Moderate Population <br /> ❑ ❑ 17. Heavy Population <br /> Structure Operation FeedingMater <br /> ❑ ❑ 18. Water Trou hs <br /> ❑ ❑ 19. Cups or Bowls <br /> 20. Food Storacie <br /> Struc re Operation HOU$e$ <br /> to o?y <br /> ❑ 21. Floors <br /> ❑ ❑ 22. Walls/Ceilings <br /> ❑ ❑ 23. Cleaning Fre uenc `. <br /> Structure Operation Water Well <br /> ❑ ❑ 1. Well Construction <br /> El El 2. Cross Connection ,� <br /> Structure Operation Floors 7K I <br /> ❑ 3. Properly Graded to Sewer <br /> ❑ ❑ 4. Drain <br /> ❑ ❑ 5. Smooth/Cleanable .- <br /> 6. Covin <br /> 7. Cleaning Frequency <br /> Structure Operation Walls <br /> ❑ ❑ . Smooth/Cleanable _ <br /> ❑ ❑ 9. Cleaning Frequency <br /> Structure Operation Cages <br /> ❑ ❑ F 10. Condition <br /> 11. Sanitation <br /> Structure Operation I Food <br /> ❑ ❑ h Lu. storage <br /> 13. Insect/Vermin <br /> Structure Operation Animal Disposal <br /> ❑ ❑ 14. Removal from Premises <br /> ❑ ❑ 15. Other <br /> Structure Operation Sewage Disposal <br /> ❑ ❑ 8. Se tic System <br /> ❑ ❑ 17. Sewer <br /> Structure Operation Rabies Vaccination RECEIVEY ---A IINSP OR <br /> ❑ El18. Certificate on Premises P <br /> VECTOR CONTROL INSPECTION FORM %_`1 �_� V <br /> EHD 40-06 4/6/12 (1 <br /> Page of <br />