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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street Stockton, CA 95202-3029 <br /> rF ;� Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd <br /> � OR <br /> VECTOR CONTROL INSPECTION FORM <br /> anownimmum <br /> DBA INSPECTION DATE <br /> Structure Operation /% <br /> ®p ® <br /> ❑ ❑ 1. Well Construction PREMISE ADDRESS RE-INSPECTION DATE <br /> ❑ ❑ 2. Cross-Connection 17 9 r <br /> Structure Operation Manure ManagemOnt OWN4VOPERATOR PHONE <br /> i <br /> El 3. Spreading and sking `d �/ - k <br /> ❑ ❑ 4. Concrete Tans INS P CTION TYPE PROGRAM ELEMENT R ORD ID <br /> 11 ❑ 5. Lagooning Z^r�e <br /> ❑ ❑ 6. Compost g The items below represent code violations and must be corrected: <br /> Structure Operation Bird Dis osal <br /> ❑ ❑ 7. Bu with 2"of over <br /> ❑ ❑ 8. A /roved Concrete Tank <br /> ❑ ❑ 9. Removal from Premises , <br /> Structure Operation V ctor Control <br /> ❑ ❑ XO. Domestic FI <br /> El 11. Fannia FI <br /> ❑ ❑ 12. Larvae 7 <br /> ❑ ❑ 13. Pupae IF <br /> ❑ 14. Adult <br /> ❑ 15. Light Population <br /> ❑ ❑ 16. Moderate Population <br /> ❑ ❑ 17. HeavyPopulation <br /> Structure 4operation FeedingNVater <br /> ❑ ❑ 18. Water Troughs _ <br /> ❑ ❑ 19. Cups or Bowis <br /> El 20. Food Storage <br /> S cture Operation Houses <br /> ❑ ❑ 21. Floors fl <br /> ❑ ❑ 22. Walls/Ceilings <br /> ❑ ❑ 23. Cleanin Fr uenc <br /> moommonsmolm <br /> Structure Operation Water Well <br /> ❑ ❑ 1. Well Construction <br /> 2. Cross Connection <br /> Structure Operation Floors <br /> ❑ ❑ 3. Proed Graded to Sewer <br /> ❑ ❑ 0 4. Drain <br /> ❑ ❑ 5. Smooth/Cleanable <br /> 6. Covin <br /> 7. Cleaning Frequency _ <br /> Structure Operation Walls e <br /> ❑ ❑ 8. Smooth/Cleanable <br /> ❑ ❑ 9. Cleaning Frequency <br /> Structure Operation Cages <br /> ❑ ❑ 10. Condition <br /> 11. Sanitation <br /> Structure Operation Food <br /> ❑ ❑nV 12. Storage <br /> 13. Insect/Vermin <br /> Structure Operation Animal Dis al <br /> ❑ ❑ 14. Removal from Premises <br /> ❑ ❑ 15. Other <br /> Structure Operation Sewage Disposal <br /> ❑ ❑ 16. Septic System <br /> ❑ ❑ 17. Sewer <br /> Structure operati Rabies Vaccination "E6 INSPECTOR <br /> ❑ ❑ 18. Certificate on Premises <br /> VECTOR CONTROL INSPECTION FORM <br /> EHD 40-06 12/04/08 <br /> Page of <br />