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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> �¢ <br /> 1868 East Hazelton Avenue, Stockton, California 95205-6232 <br /> Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd <br /> VECTOR CONTROL INSPECTION FORM <br /> MMEMEMMMM DBA a INSPECTION DATE <br /> Structure Operation ®IV//J- <br /> 1:1 <br /> /J- <br /> ❑ 1. Well Construction PREMISE ADDRESS RE-INSPECTION DATE <br /> ❑ ❑ 2. cross-Connection17 73- ^ ?z e <br /> structure Operation Manure Mana erne IOPERATOR <br /> OWN RPHONE <br /> ❑ ❑ 3. Spreading and Dis g ),0 4_ - %78--? <br /> ❑ ❑ 4. Concrete Tanks INSPECTION TYPE PROGRAM ELEMENT RECORD ID <br /> ❑ ❑ 5. Lagooning _eeo n 6.- <br /> ❑ ❑ 6. Composting The items below represent code violations and must be corrected: <br /> Structure Operation Bird Dispos <br /> ❑ ❑ 7. Burvinq wi 2"of Cover <br /> ❑ ❑ 8. A rov Concrete Tank <br /> ❑ ❑ 9. Rernoy4l from Premises <br /> Structure Operation VQCto ontrol <br /> ❑ ❑ 10. p6mestic FI <br /> El 13 11. annia Fly 2 <br /> ❑ ❑ 1i Larvae <br /> ❑ ❑ 3. Pupae <br /> ❑ ❑ 14. Adult <br /> ❑ ❑ 15. Light Population <br /> ❑ ❑ 16. Moderate Population ��+ ✓� <br /> ❑ 17. Heavy Population <br /> Structure Op4ration Feeding/Water <br /> ❑ ❑ 18. Water Troughs <br /> ❑ ❑ 19. Cups or Bowls ,, + z <br /> 20. Food Storage <br /> Structu Operation Houses <br /> ❑ 21. Floors <br /> ❑ 22. Walis/Ceilin s <br /> ❑ ❑ 23. Cleaning Frequency <br /> Structure Operation 5Me e <br /> ❑ ❑ . Well Construction r �' <br /> 2. Cross Connection <br /> Structure Operatic 00 <br /> El 0 3. Properly Graded to Sewer T <br /> ❑ ❑ 4. Drain ' <br /> ❑ ❑ 5. Smooth/Cleanable <br /> 6. Covin <br /> 7. eaning Frequency <br /> Structure Operation e 0" <br /> ❑ ❑ 8. Smooth/Cleanable <br /> ❑ ❑ 9. Cleaninq Frequency <br /> Structure Operation a <br /> ❑ ❑ 10. Condition <br /> 11. Sanitation <br /> StructureOperation O <br /> 1:1 ❑ 1-1 tora e <br /> 13. In§gcolermip <br /> Structure JE <br /> innal Dis <br /> ❑ 14. Removal from Premises <br /> ❑ 5. Other <br /> Structure Sewage Disposal <br /> ❑ 16. Septic System <br /> ❑ ❑ <br /> Structure Operati Rabies VBCCin6100 <br /> CE ED (NSP TOR <br /> ❑ 8. Certificate on Premises <br /> VECTOR CONTROL INSPECTION FORM <br /> EHD 40-06 4/6/12 <br /> Page l of <br />