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oAQut" SAN JOAQUIN COUNTY 40 <br /> w <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street Stockton, CA 95202-3029 <br /> rt4:, �� • Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd <br /> ® ® p <br /> VECTOR CONTROL INSPECTION FORM <br /> DBA 4INSPE ION D E <br /> Structure Operation -LAAA1 D 11;z 47 <br /> ❑ ❑ 1. Well Construction PREMISE ADDRESS RE-INSPECTION IYATE <br /> ❑ ❑ 2. Cross-Con ion <br /> Stricture Operation Manure Mariagernent OWN OPERATOR PHONE <br /> ❑ ❑ 3. Spreadin and Disking <br /> ❑ ❑ 4. Concre Tanks NSPICTION TYPE PROGRAM ELEMENT RECOR ID <br /> 11 [:] 5. Lag ing <br /> ❑ ❑ 6. Co sting The items below represent code violations and must be corrected: <br /> Structure Operation Bir isposal <br /> ❑ ❑ <br /> 7,burying with 2"of Cover <br /> ❑ ❑ . Approved Concrete Tank L a <br /> ❑ ❑ 9. ------'--Premises ' <br /> Structure Operatic Vector Control If <br /> ❑ 10. Domestic FI <br /> 11. Fannia Fl <br /> ❑ 12. Larvae <br /> ❑ ❑ 13. Pupae / P <br /> ❑ ❑ 14. Adult <br /> ❑ ❑ 15. Light Population V1 <br /> ❑ ❑ 16. Moderate Population r <br /> ❑ ❑ 17. Heavy Population <br /> S re Operation Feeding/Water <br /> ❑ 18. Water Troughs o <br /> ❑ 19. Cups or Bowls ® e- r- er <br /> 20. Food Storage <br /> Structure Operation Houses <br /> ❑ ❑ 21. Floors Pa&es <br /> c t <br /> 1:11122. Walls/Ceilings J <br /> ms are tto <br /> ❑ ❑ 23. Cleanin aFr uenc <br /> Structure Operation Water Well <br /> ❑ ❑ 1. Well Construction <br /> 2. Cross Connection <br /> Stu O ration Floors <br /> ❑ ❑ 3. Properly Graded to Sewer <br /> ❑ ❑ 4. Drain y Cdi ok Is r,b_fecf) <br /> ❑ ❑ 5. Smooth/Cleanable <br /> 6. Covin <br /> El 7. Cleaning Frequency <br /> Structure 40eration Walls <br /> ❑ 8. Smooth/Cleanable <br /> ❑ ❑ 9. Cleaning Frequency <br /> Structure Operation Cages <br /> ❑ ❑ 10. Condition <br /> 11. Sanitation <br /> Stnuctu tion Food <br /> ❑ ❑ 12. Storage <br /> 13. Insect/Vermin <br /> Structure operation Animal Disposal <br /> ❑ 1 ❑ 14. Removal from Premises <br /> ❑ 15. Other <br /> Structure ration Sewage Disposal <br /> ❑ ❑ 16. Septic System <br /> &9!M <br /> Lr2,u ❑ 17. Sewer <br /> tion Rabies Vaccination RE BYINSPECTOR <br /> A ❑ 18. Certificate on Premises <br /> VECTOR CONTROL INSPECTION FORM <br /> Page of <br /> EHD 40-06 12/04/08 <br /> _ <br />