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°°"i" • SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> ` `. 304 East Weber Avenue, 3`d Floor, Stockton, CA 95202-2708 <br /> cq C,:F.o R arc <br /> Telephone:(209)468-3420 Fax.(209)464-0138 Web:www.sjgov.org/ehd <br /> 0000 It 7 VECTOR CONTROL INSPECTION FORM <br /> POULTRY RANCH DBAr� p INSPE/T�ION ATTEE <br /> Structure Operation Water Well `� I ,G� C e'15 <br /> ❑ ❑ L Well Construction PREMISE ADDRESS ' t i REINSPECTION DATE <br /> 11 2. Cross-Connection 1 .79 ff� <br /> Structure Operation Manure Manage ent OW ROPE OR PHONE �( <br /> ❑ ❑ 3. Spreading an Disking K a <br /> ❑ ❑ 4. Concrete T ks I PECTIQN TYPE PROGRAM ELEMENT RECORD ID rry/ <br /> ❑ ❑ 5. Lagoonin rATI(T p C)CFS <br /> ❑ ❑ 6. Compost' g The items below represent code violations and must be corrected: <br /> Structure Operation Bird Dis al <br /> ❑ ❑ 7. Buryiri with 2"of Cover <br /> ❑ ❑ 8. Apprived Concrete Tank <br /> ❑ ❑ 9. Re oval from Premisessap- <br /> Structure Operation Vect r Control <br /> ❑ ❑ 10./Domestic Fl <br /> ❑ ❑ 1 I. Fannia Fl ,/� y ` <br /> ❑ ❑ 12. Larvae "' A I( 1 �L l�S r a(fc l m o- In / c <br /> ❑ ❑ l3. Adult <br /> CIA f NI 0,VIA OLV a�-I(X''b le 0n t-f-. <br /> ❑ ❑ 5. Light Population <br /> ❑ ❑ 116. Moderate Population <br /> ❑ ❑ j 17. Heavy Population C .`` //�� �+ �, �y <br /> Structure Operation Feeding/Water } �,( y hie ad �5 1 QO"\ S�l.oL i <br /> ❑ ❑ 18. Water Troughs <br /> ❑ ❑ 19. Cups or Bowls <br /> ❑ ❑ 20. Food Storage c�`� `I C j 0� C �/ <br /> Structure Operation Houses -•�J Y +� <br /> ❑ Jcs <br /> I ❑ 21. Floors <br /> ❑ ❑ 22. Walls/Ceilings <br /> ❑ ❑ 23. Cleaning FrequencyC <br /> KENNEL <br /> structure O ration W21.,Well <br /> ❑ 1. Well onstruction <br /> ❑ ❑ 2. Cross Connection <br /> Structure Operation Floors lX" a�i ` V V�'` I 1 Y t�� a �✓e•- a <br /> ❑ ❑ 3. Properly Graded to <br /> ❑ ❑ 4. Drain <br /> El El 5. Smooth/Cleanable r V M <br /> 1:11 El 6. Covin s V[ 7 vrr 1 <br /> ❑ ❑ 7. Cleaning Frequency <br /> Structure Operation Walls <br /> ❑ 8. Smooth/Cleanable � V�� u �� - �� � �� <br /> 101 ❑ 9. CleaningFrequency a <br /> Structure Operation Cages <br /> ❑ 10. Condition <br /> ❑ ❑ 11. Sanitation <br /> Structure Operation Food <br /> ❑ ❑ 12. Stora e <br /> ❑ ❑ 13. Insect/Vermin <br /> Structure operation Animal Disposal <br /> ❑ 4. Remo from Premises <br /> ❑ ❑ 15. Other <br /> Structure Operation Sewage Disposal <br /> ❑ ❑ 16 tem c,� p / Q <br /> ❑ 17. Sewer �l'1,C r 7 16 t4 _477%Vo <br /> Structure peralion Rabies Vaccination RECEIV B INSPECTO <br /> ❑ ❑ 18. Certificate on Premises <br /> EHD 40-06 6/30/2005 Page of <br />