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o°a"'" SAN JOA 1 COUNTY <br /> .... ....., <br /> rj ? ENVIRONMENTAL HEALTH DEPARTMENT <br /> iq { <br /> 1868 East Hazelton Avenue, Stockton, California 95205-6232 <br /> q.. -;..•;P Telephone:(209)468-3420 Fax:(209)464-0138 Web:wrwwrsjgov.org/ehd <br /> �/PORN <br /> VECTOR CONTROL INSPECTION FORM <br /> DBA INSPE TIO DATE <br /> Structure Operation �.� 7 7/jA <br /> ❑ ❑ 7gross-Connection <br /> PREMISE ADDRESS RE-INSPECTION DATE <br /> ❑ ❑Structure Operation e OrERIPPERATOR PHONE <br /> ❑ ❑ 3. Spreading and Dis ' g <br /> ❑ ❑ 4. Concrete Tanks INSPECTION TYPE PROGRAM ELEMENT REC RD ID <br /> ❑ ❑ 5. Lagooning '�`� /0 I <br /> ❑ ❑ 6. Composting The items below represent code violations and must be corrected: <br /> Structure Operation Bird Dispos <br /> 11 El7. Bu in th 2°of Cover <br /> ❑ ❑ 8. Approv6d Concrete Tank <br /> ❑ ❑ 9. Re val from Premises ° <br /> Structure Operation Vect r Control <br /> ❑ ❑ 10.homestic FI <br /> 1:1 El 13t Fannia FI <br /> ❑ ❑ . Larvae 7 <br /> ❑ ❑ V13. Pupae <br /> ❑ ❑ A 14. Adult <br /> ❑ ❑ 15. Li ht Population <br /> ❑ 16. Moderate Population <br /> ❑ 17. Heavy Population <br /> Structure O enation FeedingMater <br /> ❑ ❑ 18. Water Trou hs <br /> ❑ ❑ 19. Cups or Bowls jv<o/ ' °� <br /> El El 20. Food Storage <br /> Struct Operation Houses <br /> ❑ 21. Floors r <br /> El 22. Walls/Ceilings G64 <br /> ° <br /> ❑ ❑ 23. Cleanin Fr uenc <br /> Structure Operation <br /> ❑ ❑ 1. Well Construction <br /> 2.&Lo s Connection <br /> Structure Operation 10 r <br /> ❑ 3. Properly Graded to Sewer <br /> ❑ ❑ 4. Drain <br /> ❑ ❑ 5. Smooth/Cleanable c <br /> 6. Covin <br /> El 7. CI aning Fre uenc <br /> Structure Operation Wal <br /> ❑ ❑ 8. Smooth/Cleanable <br /> ❑ ❑ 2._Qleaning Frequency <br /> Structure Operation Ce <br /> ❑ ❑ . Condition ' <br /> 11 nitation <br /> Structure Operation FO <br /> ❑ ❑AN tora e <br /> El 0 InsecYvermin <br /> Structure Operation Animal Disposal <br /> ❑ ❑ 14. Removal from Premises <br /> ❑ ❑ 15. <br /> Structure Operation eWa <br /> ❑ ❑ 16. Septic System <br /> El El17. Sewer <br /> Structure Operation able Vaccinatio R EIVED INSP C OR <br /> ❑ ❑ Certificate on Premises <br /> VECTOR CONTROL INSPECTION FORM <br /> EHD 40-06 4/6/12 <br /> Page'of <br />