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SAN JOAQUIN COUNTY <br /> < ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street Stockton, CA 95202-3029 <br /> c�4:.- ;.:•;P Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd <br /> �rFOR� <br /> VECTOR CONTROL INSPECTION FORM <br /> FAMM DBA ® "e INSPECTION DTE <br /> Structure OperationWater Well e�ws- Z <br /> ❑ ❑ 1. Well Construction PREMISE ADDRESS a RE-INSPECTION DATE <br /> ❑ ❑ 2. cross-connection eJ <br /> Structure Operation Manure Management OWNER/OPERATOR V PHONE <br /> ❑ ❑ 3. Spreading and Disking / ` <br /> ❑ ❑ 4. Concrete Tanks INSPECTION TYPE PROGRAM ELEMENT RECORD ID <br /> ❑ 5. Lagooning <br /> ❑ ❑ 6. Composting The items below represent code violations and must be corrected: <br /> Structure Operation Bird Disposal <br /> ❑ ❑ 7. Burying with 2"of Cover ° <br /> ❑ ❑ 8. Approved Concrete Tank <br /> ❑ ❑ 9. Removal from Premises <br /> Structure Operation Vector Control <br /> ❑ ❑ 10. Domestic FI <br /> 11. Fannia FI <br /> ❑ ❑ 12. Larvae <br /> ❑ ❑ 13. Pupae „ <br /> ❑ ❑ 14. Adult <br /> ❑ ❑ 15. Light Population <br /> ❑ ❑ 16. Moderate Population <br /> ❑ ❑ 17. Heavy Population_ fl <br /> Structure Operation Feeding/Water ee�l <br /> ❑ ❑ 1 18. Water Troughs <br /> ❑ ❑ 19. Cups or Bowls <br /> 20. Food Storage <br /> Structure Operation Houses <br /> ❑ ❑ 21. Floors <br /> ❑ ❑ 22. Walls/Ceilings <br /> ❑ ❑ 23. Cleanin Fre uenc <br /> Structure Operation Water Well _ <br /> ❑ ❑ 1. Well Construction f- /4 <br /> 2. Cross Connection <br /> Structure Operation Floors <br /> ❑ ❑ 3. Proed Graded to Sewer <br /> ❑ ❑ 4. Drain r <br /> ❑ ❑ 5. Smooth/Cleanable <br /> 6. Covin <br /> 7. Cleaning Frequency <br /> Structure Operation Walls <br /> ❑ ❑ 8. Smooth/Cleanable <br /> ❑ ❑ 9. Cleaning Frequency <br /> Structure Operation Cages <br /> ❑ ❑ 10. Condition <br /> 11. Sanitation <br /> Structure Operation Food <br /> ❑ ❑ 12. Storage <br /> 13. Insect/Vermin <br /> Structure Operation Animal Dis al <br /> ❑ ❑ 14. Removal from Premises <br /> ❑ ❑ 15. Other <br /> Structure Operation Sewage Disposal <br /> ❑ ❑ 16. Septic System <br /> ❑ ❑ 17. Sewer <br /> Structure Operation Rabies VaccinationRE EIVED BY IN CTOR <br /> 111:118. Certificate on Premises <br /> VECTOR CONTROL INSPECTION FORM <br /> EHD 40-06 12/04/08 <br /> Page of <br />