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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street Stockton, CA 95202-3029 <br /> rte:., ;.:•;� Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd <br /> �rFOR� <br /> VECTOR CONTROL INSPECTION FORM <br /> ISIMIMENEW DBA INSPECTION DATE <br /> Structure Operation <br /> ❑ ❑ 1. Well Construction PREMISE ADDRESS RE-i PEC ON DATE <br /> ❑ ❑ 2. Cross-Connection givd. <br /> Structure Operation Manure management OWNER/OPERATOR IJ PHONE <br /> ❑ ❑ 3. Spreading and DiskingKgd�t (20cl -- <br /> ❑ ❑ 4. Concrete Tanks IN SP CTION TYPE V PROGRAM ELEMENT RECORD ID <br /> ❑ ❑ 5. LagooningqV <br /> ❑ ❑ 6. composting The items b6l6w represent code violations and mus be corrected: <br /> Structure Operation Bird Disposal <br /> ❑ ❑ 7. Burying with 2"of Cover <br /> ❑ 1 8. Approved Concrete Tank <br /> ❑ 9. Removal from Premises <br /> r <br /> Structure operation Vector Control <br /> ❑ ❑ 10. Domestic FI <br /> El 11. Fannia FI <br /> ❑ ❑ 12. Larvae <br /> ❑ ❑ 13. Pupae <br /> ❑ ❑ 14. Adult <br /> ❑ ❑ 15. Light Population <br /> ❑ ❑ 16. Moderate Population CS S^ <br /> ❑ ❑ 17. Heavy Population <br /> Structure Operation I Feeding/Water <br /> ❑ ❑ 18. Water Troughs <br /> ❑ ❑ 19. Cups or Bovis ( n r p 1 <br /> El El 20. Food Storage <br /> Structure Operation Houses <br /> ❑ ❑ 21. Floors <br /> ❑ ❑ 22. Walls/Ceilings <br /> ❑ ❑ 23. Cleanin Fr uenc <br /> mmmmmmmmmm <br /> Pp <br /> Structure Operation Water Well <br /> ❑ ❑ 1. Well Construction <br /> 2. Cross Connection <br /> Structure Operation Floors <br /> ❑ 3. Properly Graded to Sewer <br /> ❑ ❑ 4. Drain <br /> ❑ a 5. Smooth/Cleanable <br /> El 6. Covin <br /> 7. Cleaning Frequency <br /> Structure Operation Walls <br /> ❑ 0 8. Smooth/Cleanable <br /> ❑ ❑ 1 9. Cleaning Frequency <br /> Structure Operation Cages <br /> ❑ ❑ 10. Condition <br /> 11. Sanitation <br /> Structure Operation Food <br /> ❑ V ❑ 12. Storage <br /> 13. InsecWermin <br /> Structure Operation Animal Dis oral <br /> ❑ ❑ 14. Removal from Premises <br /> ❑ ❑ 15. Other <br /> Structure Operation Sewage Disposal <br /> ❑ ❑ 16. Septic System <br /> ❑ ❑ 17. Sewer <br /> Structure O r*tkm Rabies Vaccination RECE Y INSPECTOR <br /> -06 <br /> ❑ ❑ 18. Certificate on Premises `{ <br /> VECTOR CONTROL INSPECTION FORM <br /> EHD 40-06 12/04/08 �7 <br /> Page /of <br />