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®Pa U i N- � SAN JOAQUIN COUNTY <br /> 4 ENVIRONMENTAL HEALTH DEPARTMENT" <br /> toij <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 r INSPE TION DATE <br /> Structure Operation Water Well <br /> ❑ ❑ 1. Well Construction PREMISE ADDRESS REI PECTIO DATE <br /> ❑ ❑ 2. Cross-Connection <br /> Structure Operation Manure Management O NER/ PERATOR PHONE <br /> rq <br /> 13 El3. Spreading and Disking I I A <br /> ❑ ❑ 4. Concrete Taifs IN ECTION TYPE PROGRAM ELEMENT RECORD ID <br /> ❑ 5. Lagooning <br /> 116. Compostin T e items below represent code violations and must be corrected: <br /> Structure Operate n Bird DlspoS <br /> ❑ ❑ 7. Bu in ith Y'of Cover <br /> ❑ ❑ 8. ApproAd Concrete Tank ++ , <br /> ❑ 9. Rem al from Premises L t�-- <br /> Structure Operation ector ontrol <br /> ❑ ❑ N. D mestic Fl 1 <br /> ❑ ❑ 1 l annia Fl <br /> ❑ ❑ 12.YLarvae <br /> ❑ ❑ 1 kipae _nQ <br /> 1:1 El4. A It Z i C.�tA <br /> j r3 t1'5 <br /> ❑ ❑ 15. LigXt Population <br /> ❑ Cl 16. Mod ate Po ulation <br /> ❑ ❑ 17. Heav o ulation n <br /> Structure Opera n Feeding/W er <br /> ❑ 18. Water Tr hs <br /> ❑ ❑ 19. Cups or Bowls <br /> ❑ ❑ 20. Food Stora e <br /> Structure Operation Houses <br /> ❑ ❑ 21. Floors <br /> ❑ ❑ 22. Walls/Ceilin s <br /> ❑ ❑ 23. leaning Fre uenc <br /> KENNEL <br /> Structure Operation Water Well <br /> ❑ EEI 1. Well Construction <br /> ❑ ❑ 2. Cross Connection <br /> Structure Operation Floors <br /> 3. Properly Graded to <br /> ❑ ❑ 4. Drain >.� <br /> ❑ ❑ 5. Smooth/Cleanable <br /> ❑ D 6. Covin <br /> ❑ ❑ 7. Cleaning Frequencyj <br /> Structure Operation Walls <br /> 8. Smooth/Cleanable <br /> ❑ El 9. Cleaning Fre uenc <br /> Structure Operation Cages <br /> ❑ ❑ 10. Condition <br /> ❑ 0 11. Sanitation <br /> Structure Operation Food <br /> ❑ ❑ 12. Storage <br /> ❑ 0 13. Insect/Vermin <br /> Structure Operation Animal Disposal <br /> 11 ❑ 14. Removal from Premises <br /> 11 ❑ 15. Other <br /> Structure Operation Sewage Disposal <br /> ❑ ❑ 1 16. Septic System <br /> ❑ ❑ 17. Sewer <br /> Structure Operation Rabies Vaccination ECEIV D BY INSPECTO <br /> ❑ ❑ 18. Certificate on Premises <br /> EHD 40-06 6/30/2005 VPageOf ) <br />