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oA°`"�"'' SAN JOAQUIN COUNTY <br /> r ,rrr ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, California 95205-6232 <br /> •.. ;P <br /> Telephone:(209) 468-3420 Fax:(209) 464-0138 Web:www.sjgov.org/ehd <br /> a�IFOR� ® �® <br /> VECTOR CONT INSPECTION FORM <br /> DBA INSP�C ON DA E <br /> Structure Operation 7 <br /> ❑ ❑ 1. Well Construction PREMISE ADDRESS Z0, RE-INSPECTION DATE <br /> ❑ ❑ 2. Cross-Connection 13 7 Y/ ! <br /> Structure Operation Manure Mana em t OWNE 4 ERATOR P ONE <br /> ❑ ❑ 3. Spreading and Diking A2 A? .k' -1 7J S 7 x <br /> ❑ ❑ 4. Concrete Tan INSPECTION TYPE PROGRAM ELEMENT RECORD ID <br /> El ❑ 5. Lagooning csbl <br /> ❑ ❑ 6. Compostin The items below represent code violations and must be corrected: <br /> Structure Operation Bird Dispg6al <br /> ❑ ❑ 7. BuryinAith 2°of Cover <br /> ❑ ❑ 8. Approlved Concrete Tank <br /> ❑ ❑ 9. Re oval from Premises <br /> Structure Operation Ve Or control <br /> ❑ ❑ 1 Domestic FI <br /> 1. Fannia FI <br /> LEE11 ❑ 12. Larvae❑ 13. Pu ae <br /> ❑ 14. Adult <br /> 15. Li ht Po ulation <br /> 16. Moderate Po ulation <br /> 17. Hea Po ulation <br /> peretion FeedingMlater <br /> ❑ 18. Water Trou hs <br /> ❑ 19. Cups or Bowls <br /> 20. Food Storage <br /> Struct operation Houses <br /> ❑ 21. Floors <br /> El22. Walls/Ceilin s <br /> T❑ ❑ 1 23. Cleanin Fre uen <br /> Structure Operatio ater <br /> ❑ ❑ all Construction !� <br /> El ross Connection <br /> Structure Operati FI r <br /> Pro erl Graded to Sewer t <br /> ❑ ❑ 4. Drain <br /> ❑ ❑ 1 5. Smooth/Cleanable <br /> 6. Covin <br /> El 7. Cleaning Frequency <br /> Structure Operation Walls <br /> ❑ ❑ 8. Smooth/Cleanable <br /> ❑ ❑ g_. fj@qLing Frequency <br /> Structure Operatio Ca <br /> ❑ ❑ O. Condition <br /> tion <br /> Structure Operati <br /> fAmyff- <br /> 11 ❑ 12. Stora e <br /> 13 3. Insect/Vermin <br /> Structure Operation Animal Disposal <br /> ❑ ❑ 14. Removal from Premises <br /> ❑ ❑ 15. Other <br /> Structure Operation Sewage Disposal <br /> ❑ ❑ Se tic System <br /> ❑ 17 <br /> Structure Operation Rabies Vaccinati RECEI B IN CTO I <br /> l _,_,W <br /> ❑ ❑ 8. Certificate on Premises <br /> VECTOR CONTROL INSPECTION FORM <br /> EHD 40-06 4/6/12 <br /> Page ` of <br />