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SAN JOAQUIN COUNTY <br /> a ENVIRONMENTAL HEALTH DEPARTMENT <br /> { 304 East Weber Avenue, 3rd Floor, Stockton,CA 95202-2708 <br /> Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd <br /> VECTOR CONTROL INSPECTION FORM <br /> POULTRY RANCH DBA INSPE TION DATE <br /> Structure Operation Water Well 5 LAV1, V 1 I L'; <br /> ❑ ❑ 1. Well Construction PREMISE ADDRESS REINSPECTION DATE <br /> ❑ ❑ 2. Cross-Connection ® - <br /> Structure Operation Manure Management OWNER/OPE TOR PHONE <br /> ❑ ❑ 3. Spreading and Disking <br /> ❑ ❑ 4. Concrete Tanks INSPEC ION TYPE PROGRAM ELEMENT RECORD ID _ <br /> ❑ 5. Lagooning -A <br /> ❑ ❑ 6. Composting The items below represent code violations and must be correcte <br /> Structure Operation Bird Disposal <br /> ❑ ❑ 7. BuEying with Y'of Cover Lo 14 ` ILW5 LA l <br /> ❑ ❑ 8. Approved Concrete Tank <br /> ❑ ❑ 9. Removal from Premises <br /> Structure Operation Vector Control <br /> ❑ 0 10. Domestic Fl <br /> ❑ <br /> 11. Fannia FI <br /> ❑ El 12. Larvae OL 6% <br /> ❑ El 13. Pupae <br /> ❑ ❑ 14. Adult C <br /> ❑ ❑ 15. Light Population <br /> ❑ ❑ 16. Moderate Population <br /> ❑ ❑ 17. Heavy Population ` P <br /> Structure Operation Feeding/Water • ( ly- /` ,Q„�/11�D�1�.TS 6 <br /> 11 ❑ 18. Water Troughs <br /> ❑ ❑ 19. Cups or Bowls ' l`f. <br /> ❑ ❑ 20. Food Stora e <br /> Structure Operation Houses �- ft <br /> `�'�� t..�• l <br /> ❑ ❑ 21. Floors <br /> ❑ ❑ 22. Walls/Ceilin <br /> ❑ ❑ 23. Cleaning Fre <br /> K E N NEL <br /> Structure Operation Water Well <br /> ❑ ❑ 1. Well Construction r L <br /> ❑ ❑ 2. Cross Connection. <br /> Structure Operation Floors <br /> ❑ ❑ 3. Properly Graded to <br /> ❑ ❑ 4. Drain <br /> ❑ 0 5. Smooth/Cleanable <br /> El ❑ 6. Covin <br /> ❑ ❑ 7. Cleaning Frequency <br /> Structure Operation Walls <br /> ❑ El 8. Smooth/Cleanable 4 <br /> ❑ El 9. Cleaning Frequency <br /> Structure Operation Cages s <br /> ❑ ❑ 10. Condition VI.L <br /> a <br /> Q 11. Sanitation <br /> Structure Operation Food <br /> ❑ ❑ 12. Storage C <br /> ❑ ❑ 13. InsectNermin <br /> Structure Operation Animal Disposal <br /> ❑ ❑ 14. Removal from Premisee <br /> ❑ ❑ 15. Other <br /> Structure Operation Sewage Disposal <br /> ❑ 0 16. Septic System <br /> ❑ ❑ 17. Sewer <br /> Structure Operation Rabies Vaccination RE El ED BY IN ECTOR <br /> ❑ 18. 0 LO <br /> Certificate on Premises <br /> EHD 40-06 6/30/2005 Page Of <br />