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is <br /> �OAQutN VAN JOAQUIN COUNTY <br /> .•^ '••.CO <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, California 95205-6232 <br /> . �Q.• :•a;P Telephone:(209) 468-3420 Fax:(209) 464-0138 Web:www.sjgov.org/ehd <br /> �rFOR <br /> VECTOR CONTROL INSPECTION FORM <br /> ffiffiJIMMMEM 7DB INSPE TIO®�Nr ®E/J <br /> Structure Operation ~� % (� <br /> ❑ ❑ 1. Well Construction MISE DDRESS RE-INSPECTION DATE <br /> ❑ ❑ 2. Cross-Connection 3.2 d -7Structure Operation Manure Mana eme t E PERAT R PONE t / <br /> ❑ ❑ 3. Spreading and Di ing , '9) �- s®®Y <br /> ❑ ❑ 4. Concrete Tanks INSP CTION TYPE PROGRAM ELEMENT RECORD ID <br /> ❑ ❑ 5. Lagooning S® <br /> ❑ ❑ 6. Composting/ The items below represent code violations and must be corrected: <br /> Structure Operation Bird Dlspo al <br /> ❑ ❑ 7. Bu in ith 2'of Cover , 9 <br /> ❑ ❑ 8. A r ed Concrete Tank <br /> r <br /> ❑ ❑ 9. Re oval from Premises a <br /> Structure Operation Ve or Control <br /> ❑ ❑ 1 Domestic FI <br /> 1. Fannia FI <br /> ❑ ❑ 12. Larvae <br /> ❑ ❑ 13. Pupae <br /> ❑ ❑ 14. Adult <br /> ❑ 15. Light Population <br /> ❑ 16. Moderate Population <br /> ❑ ❑ 17. Heavy Population <br /> Structure Operation Feeding/Water <br /> ❑ ❑ 18. Water Troughs <br /> ❑ ❑ 19. Cups or Bowls <br /> 20. Food Storage <br /> Str Lure Operation Houses `1/ <br /> ❑ 21. Floors <br /> ❑ ❑ 22. Walls/Ceilings <br /> ❑ j ❑ 23. Cleaninq Frequency <br /> Structure Operation Water Well <br /> ❑ ❑ 1. Well Construction <br /> 2. Cross Connection <br /> Structure Operation Floors <br /> ❑ 3. Properly Graded to Sewer <br /> ❑ ❑ 4. Drain <br /> ❑ ❑ 5. Smooth/Cleanable <br /> El 6. Covin <br /> El 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 Disposal <br /> ❑ ❑ 14. Removal from Premises <br /> ❑ ❑ 15. Other <br /> Structure Operation Sewage Disposal <br /> ❑ ❑ 16. Septic System <br /> ❑ ❑ 17. Sewer <br /> Structure Operation Rabies Vaccination RE C IV D Y 4 INSPE TOR <br /> El 1118. Certificate on PremisesYtA <br /> VECTOR CONTROL INSPECTION FORM / <br /> EHD 40-06 4/6/12 Page d of <br />