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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street Stockton, CA 95202-3029 <br /> • c��:. . .:.��. Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd <br /> VECTOR CONTROL INSPECTION FORM <br /> ESIMMEEM DBA9 S INSPECTION DA E <br /> Structure Operation / <br /> ❑ ❑ 1. Well Construction PREMISE ADDRESS n RE-INSPECTION DATE <br /> ❑ ❑ 2. Cross-Connection 3� ® s <br /> Structure Operation Manure Mana em t OWN R/OPERATOR V PHONE <br /> ❑ ❑ 3. Spreading and Di tng ®1' 6 f) I ?X-- r 7"Ir., <br /> ❑ ❑ 4. Concrete Tanks INSPECTION TYPE PROGRAM ELEMENT RECORD <br /> El [15. Lagooning 41,V54 lr,04zo SIS <br /> ❑ ❑ 6. composting The items below represent code violations and must be corrected: <br /> Structure Operation Bird Dispo I <br /> ❑ ❑ 1 7. BuryingAith 2"of Cover J' <br /> ❑ ❑ 8. A r ed Concrete Tank <br /> ❑ ❑ 9. Re oval from Premises ° <br /> Structure Operation Ve r Control <br /> ❑ ❑ 10 Domestic FI <br /> 11 1 . Fannia FI <br /> ❑ A2. Larvae ' <br /> ❑ ❑ 113. Pu ae <br /> ❑ ❑ 14. Adult <br /> ❑ ❑ 15. Light Population <br /> rj <br /> ❑ 16. Moderate Population <br /> ❑ 17. Heavy Population <br /> Structure oration Feeding/Water <br /> ❑ ❑ 18. Water Troughs <br /> ❑ ❑ 19. Cups or Bowls ® � <br /> El 20. Food Storage <br /> Sfiuc Operation Houses <br /> ❑ 21. Floors <br /> rh �, <br /> ❑ 22. Walls/Ceilings <br /> ❑ ❑ 23. Cleanin Fre uenc <br /> REIM <br /> Structure Operation Water Well <br /> ❑ ❑ 1. Well Construction <br /> Cross Connection <br /> Structure Operation Floors <br /> ❑ ❑ 3. Properly Graded to Sewer <br /> ❑ ❑ nd 4. Drain xe- <br /> ❑ ❑ 5. Smooth/Cleanable <br /> El ❑ 6. Covin <br /> El 7. Cleaning Frequency <br /> Structure Operation Walls <br /> ❑ ❑ 8. Smooth/Cleanable <br /> ❑ ❑ 9. Cleaning Frequency <br /> -- o"C, <br /> Structure Operation Cages <br /> ❑ ❑ Condition <br /> 11. Sanitation <br /> Structure Operas Food <br /> ❑ ❑ 12. Storage <br /> El El 13. Insect/Vermin <br /> Structure Operation Animal Disposal <br /> ❑ ❑ 4. Removal from Premises <br /> ❑ ❑ 15. Other <br /> Structure Operation Sewage Disposal <br /> ❑ ❑ O 6. SepticSystem <br /> ❑ ❑ 17. Sewer <br /> Structure Operation Rabies Vaccination RECEI BY P CTOR <br /> El El ID Certificate on Premises � � <br /> VECTOR CONTROL INSPECTION FORM <br /> EHD 40-06 12/04/08 <br /> Page of <br />