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oPQ�r" SAN JOAQUIN COUNTY <br /> _ rrk ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, California 95205-6232 <br /> Telephone:(209) 468-3420 Fax:(209)464-0138 Web:WWW.sjgov.org/ehd <br /> �l FOR <br /> VECTOR CONTROL INSPECTION FORM <br /> DBA INSPECTION DATE <br /> Structure Operation ! 411 /Y <br /> ❑ ❑ 1. Well Construction PREMISE ADDRESS RE-INSPECTION DATE <br /> ❑ ❑ 2. Cross-Connection Q/7 -7S- <br /> Structure Operation Manure Mana em t OWNE OPERATOR PIJONE <br /> ❑ ❑ 3. Spreading and Di ing '// �l,��j= V76P <br /> ❑ ❑ 4. Concrete Tank INSPECTION TYPE PROGRAM ELEMENT RECORD ID <br /> ❑ ❑ 5. Lagooning 6 f <br /> ❑ ❑ 6. Compos tin The items below represent code violations and must be corrected: <br /> Structure Operation Bird Dlsp al <br /> ❑ ❑ 7. Bu in with 2°of Cover <br /> ❑ ❑ 1 8. Appo4vd Concrete Tank <br /> ❑ ❑ 9. R oval from Premises <br /> Structure Operation Ve or Control <br /> ❑ ❑ 1jt Domestic FI <br /> El El 1. Fannia FI f <br /> ❑ ❑ 12. Larvae <br /> ❑ ❑ 13. Pupae <br /> ❑ ❑ 14. Adult <br /> ❑ 15. Light Population <br /> ❑ 16. Moderate Population 61 <br /> ❑ ❑ 17. Heavy Population <br /> Structure Operation Feeding/Water <br /> ❑ ❑ 18. Water Troughs <br /> ❑ ❑ 19. Cups or Bowls <br /> 20. Food Storage <br /> St r cture Operation Houses <br /> ❑ ❑ 21. Floors <br /> ❑ ❑ 22. Walls/Ceilings <br /> ❑ ❑ 1 23. Cleaning Frequency <br /> Structure Operatio Water <br /> ❑ ❑ 1. Well Construction <br /> 2. CrossConnection <br /> Structure Operation I �. ✓�► / <br /> 1:1 El 3. Pro erlGraded to Sewer <br /> ❑ ❑ 4. Drain <br /> ❑ ❑ 5. Smooth/Cleanable <br /> El El 6. Covin '_ H F, <br /> El Ej 7._9gLaning Frequency <br /> Structure Operation W IIS <br /> ❑ ❑ 8. Smooth/Cleanable <br /> ❑ ❑ 9. Cleaning Frequency <br /> Structure Operationges <br /> ❑ ❑ 10. Condition J r <br /> El anitation <br /> Structure Operation p <br /> ❑ ❑ Stora e <br /> 13. Inse ermin <br /> Structure OperatloA ApAal DispQsall <br /> ❑ ❑ oval from Premises <br /> ❑ ❑ 15. Other <br /> Structure Operation Sewage Disposal <br /> ❑ ❑ Septic System <br /> ❑ ❑ 17. S <br /> Structure Operatio abies V R CEI BINSP CTOR <br /> 11 1018. Certificate on Premises <br /> VECTOR CONTROL INSPECTION FORM <br /> EHD 40-06 4/6/12 <br /> Page ` of <br />