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A0."'" SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> N X <br /> An <br /> 1868 East Hazelton Avenue, Stockton, California 95205-6232 <br /> • q.. ::.N;P• Telephone:(209)468-3420 Fax:(209) 464-0138 Web:www.sjgov.org/ehd <br /> /FOR ® CONTROL <br /> p� ®pp <br /> VECTOR CONT INSPECTION FORM <br /> DBA INSPECTION DATE <br /> -71 Structure Operation Water Well <br /> ❑ ❑ 1. Well Construction PREMISE ADDRESS RE-INSPECTION DATE <br /> ❑ ❑ 2. Cross-Connection--/- a <br /> @ <br /> Structure Operation Manure Mana eme OWNER/OPERATORP ONE <br /> ❑ ❑ 3. Spreading and Dis ng ,, 4_ <br /> ❑ ❑ 4. Concrete Tanks INSPE ION TYPE PROGRAM ELEMENT RECORD ID <br /> ❑ E] 5. Lagooning /� <br /> ❑ ❑ 6. Composting The items below represent code violations and must be corrected: <br /> Structure Operation Bird DISpoS <br /> ❑ ❑ 7. Burvinqw, 2°of Cover <br /> ❑ ❑ 8. ApprovdConcrete Tank <br /> ❑ ❑ 9. Remo al from Premises <br /> Structure Operation Vecto Control <br /> ❑ ❑ 10. mestic FI <br /> El El 11. annia FI <br /> ❑ ❑ 1 VLarvae 21.5, s <br /> ❑ ❑ A Pupae <br /> ❑ ❑ 14. Adult <br /> ❑ ❑ j 15. Light Population <br /> ❑ ❑ 16. Moderate Population <br /> ❑ 17. Heavy Population <br /> Structure O tion Feeding/Water <br /> ❑ ❑ 18. Water Troughs - / <br /> ❑ ❑ 19. Cups or Bowls �s <br /> El 20. Food Storage <br /> Structure/ Operation Houses <br /> ❑ ❑ 21. Floors r <br /> LL ❑ 22. Walls/Ceilings <br /> ❑ 23. Cleaning Fre gen <br /> , WOMMEMMIM <br /> Structure Operation Water Welllye <br /> y <br /> ❑ ❑ Well Construction <br /> 2. Cross Connection <br /> Structure Operation Floors <br /> El 3. Pro erlGraded to Sewer <br /> ❑ ❑ 4. Drain <br /> ❑ ❑ 5. Smooth/Cleanable <br /> El El 6. Covin 'G < <br /> El n 7. Cleaning Frequency <br /> Structure Operation Walls <br /> ❑ ❑ . Smooth/Cleanable 04 <br /> ❑ ❑ 9. Cleaning Frequency <br /> Structure Operation Cages <br /> ❑ ❑ . Condition <br /> 11. Sanitation <br /> Structure Operation Food <br /> ❑ ❑ 2. Storage <br /> 13. Insect/Vermin <br /> Structure Operation Animal Disposal <br /> ❑ ❑ 4. Removal from Premises <br /> ❑ ❑ 15. Other <br /> Structure Operation j Sewage Disposal <br /> ❑ P6. Septic System <br /> ❑ ❑ 17. Sewer <br /> Structure Operation Rabies Vaccination E B _ SPECT R <br /> 11 El18. Certificate on Premises e <br /> VECTOR CONTROL INSPECTION FORM <br /> EHD 40-06 4/6/12 <br /> Page_of <br />