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,ora"'" SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> to X <br /> :=. 1868 East Hazelton Avenue, Stockton, California 95205-6232 <br /> • aq.,: ::,..;e Telephone:(209) 468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd <br /> Clp0Ftti <br /> VECTOR CONTROL INSPECTION FORM <br /> [DBA INSPECTION DATE <br /> Structure OperationWater Well <br /> ❑ ❑ 1. Well Construction PREMISE ADDRESS RE-INSPECTION DATE <br /> ❑ ❑ 2. Cross-Connection / <br /> Structure Operation Manure Mana eme t OWN R/OPERATOR PHONE <br /> ❑ ❑ 3. Spreading and Di ing )702 7- S <br /> ❑ ❑ 4. Concrete Tanks INSPECTION TYPE PROGRAM ELEMENT RECORD ID <br /> ❑ ❑ 5. Lagooning 411 / <br /> ❑ ❑ 6. Composting The items below represent code violations and must be corrected: <br /> Structure Operation Bird DispO al <br /> ❑ ❑ 7. Bu in ith 2°of Cover <br /> ❑ ❑ 8. Appr ed Concrete Tank <br /> ❑ ❑ 9. Re oval from Premises s <br /> Structure Operation VeC r Control <br /> ❑ ❑ 10 Domestic FI <br /> El El 9. Fannia FI <br /> El 1:1 12. Larvae - a !-fit <br /> ❑ ❑ 13. Pupae <br /> ❑ ❑ 14. Adult <br /> ❑ 15. Li ht Population <br /> ❑ 11 16. Moderate Population <br /> ❑ ❑ 17. Heavy Population <br /> Structure Operation Feeding/Water <br /> ❑ ❑ 18. Water Troughs <br /> ❑ ❑ 19. Cups or Bowls ® y� <br /> 20. Food Storage <br /> Str ture Operation houses <br /> ❑ ❑ 21. Floors <br /> ❑ ❑ 22. Walls/Ceilings ® ® Yt f <br /> ❑ ❑ 23. Cleanino Fre uenc <br /> Structure operation ater <br /> ❑ ❑ 1. Well Construction <br /> El Cross Connection <br /> Structure OperationFltao <br /> 1:1 El :� roperly Graded to Sewer _ <br /> ❑ ❑ 4. Drain <br /> ❑ ❑ 5. Smooth/Cleanable <br /> 6. Covin <br /> El El Z=2!�gning Frequency <br /> Structure Operation Wall!- <br /> 0 ❑ Smooth/Cleanable <br /> ❑ ❑ t -9. <br /> .Ciegninq Frequencyd <br /> Structure Operation Ca <br /> ❑ ❑ 0. Condition <br /> nitation <br /> Structure Operation F <br /> ❑ ❑ 12. Storage <br /> 13. Insec ermin <br /> Structure Operation nimal D' of <br /> ❑ ❑ 1 . Removal from Premises <br /> ❑ ❑ 15. Other <br /> Structure Operation Sewage Disposal <br /> ❑ ❑ 16. Septic System <br /> ❑ ❑ nl <br /> Structure Operation Rabies Vaccination RECEIVE IN E TO <br /> ❑ ❑ eon Premises <br /> VECTOR CONTROL INSPECTION FORM <br /> EHD 40-06 4/6/12 Page Of <br />