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QgiN SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, California 95205-6232 <br /> Telephone:(209)468-3420 Fax;(209)464-0138 Web;www.sjgov.org/ehd <br /> <<FOR <br /> VECTOR <br /> CONTROL <br /> Ng® L SErg' N FORM <br /> DBA INSPECCTI ATE <br /> Structure OperationWater Well & <br /> ❑ ❑ 1. Weil construction PREMISE <br /> �ADDRESS, RE-INSPECTION DATE <br /> ❑ ❑ 2. Cross-Connection_/_ J <br /> Structure Operation Manure Mana eme OWNER/OPERATORPHONE11 E] 3. Spreading and Dis g / <br /> �� l /—? " '7 f 0 7 <br /> ❑ ❑ 4. Concrete Tanks (NSPE TION TYPE PROGRAM ELEMENT RECORD ID <br /> ❑ ❑ 5. Lagooning IV 0 <br /> ❑ ❑ 6. Composting The items below represent code violations and must be corrected: <br /> Structure Operation Bird Dispose <br /> P� <br /> ❑ ❑ 7. Bu in wi 2"of Cover <br /> ❑ ❑ 8. Approve Concrete Tank , <br /> ❑ ❑ 9. Remo4l from Premises <br /> Structure Operation Vector ontrol <br /> ❑ ❑ 10. mestic FI <br /> 11. annia FI <br /> ❑ ❑ Larvae <br /> ❑ ❑ 4 3. Pupae <br /> ❑ ❑ Y 14. Adult <br /> ❑ ❑ 15. Light Population <br /> ❑ 16. Moderate Population ° <br /> ❑ in 17. Heavy Population <br /> Structure .ration Feeding/Water <br /> ❑ ❑ 18. Water Troughs <br /> ❑ j ❑ 19. Cups or Bowls <br /> El F1 20. Food Stora e <br /> Struc re Operation Houses <br /> ❑ 21. Floors <br /> ❑ ❑ 22. Walls/Ceilings <br /> ❑ ❑ 23. Cleaning Fre gen <br /> Structure Operation W r <br /> well construction <br /> Gross Connection <br /> Structure Operatio Fiodrs <br /> El EI I-e—Fri'operly Graded to Sewer <br /> ❑ ❑ 4. Drain C, q(' <br /> ❑ ❑ Smooth/Cleanable <br /> 6. Covin <br /> El 0 7. Cleaning Frequency <br /> Structure Operatio aHa <br /> ❑ ❑ Smooth/Cleanable <br /> ❑ ❑ 9. Cleaning Frequency <br /> r <br /> Structure Operation Ca <br /> ❑ ❑ ondition <br /> El El itation <br /> Structure Operatio Op <br /> ❑ ❑ Stora e <br /> 13. Insect/Vermin <br /> re Op <br /> Structueration mal Disposal <br /> ❑ ❑ 14. Removal from Premises <br /> ❑ ❑ r <br /> Structure op.ratio Sewage Dis <br /> ❑ -n-9--p-tic System <br /> ❑ ❑ ewer <br /> Structure Operatio Rabies Vaccinatio RECfifV D BY (NSPE OR <br /> ❑ ❑ i icate on Premises - ` ✓ ' A <br /> VECTOR CONTROL 1 SPECTION FORM <br /> EHD 40-06 4/6/12 Page_jOf <br />