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p4"i" • SAN JOAOUIN COUNTY <br /> ter, 2 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 /> <<FORN <br /> VECTOR CONTROL INSPECTION FORM <br /> n DBA <br /> INSP ON D <br /> (Vt 'Structure Operation <br /> E3 <br /> 16 <br /> ❑ 1. Well Construction PREMISE ADDRE 1 _ p RE-INSPECTI N DATE <br /> ❑ ❑ 2. Cross-Connection 2. 2& <br /> Structure Operation Manure Management OWN O E ATOR PHONE <br /> ❑ ❑ 3. Spreading and Disking � I r V <br /> ❑ ❑ 4. Concrete Tanks INSPECTION TYPE PROGRAM ELEMENT CORD L_J& <br /> 1:1 ❑ 5. Lagooning Cbm + - <br /> ❑ ❑ 6. Composting The items below represent code violations and must be corrected: <br /> Structure Operation Bird Disposal <br /> t <br /> ❑ ❑ 7. Burying with 2"of Cover <br /> ❑ ❑ 8. Approved Concrete Tank ��- <br /> ❑ ❑ 9. Removal from Premises G 4- it ttis <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 <br /> Structure Operation Feeding/Water <br /> ❑ ❑ 18. Water Troughs <br /> ❑ ❑ 19. Cups or Bowls <br /> E1 n 20. Food Storage <br /> Structure Operation Houses <br /> ❑ ❑ 21. Floors <br /> ❑ ❑ 22. Walls/Ceilings <br /> ❑ ❑ 1 23. Cleaning Fre uenc <br /> Structure Operation Water Well <br /> ❑ ❑ 1. Well Construction <br /> 2. Cross Connection <br /> Structure Operation Floors <br /> ❑ ❑ 1 3. Properly Graded to Sewer <br /> ❑ ❑ 4. Drain <br /> ❑ ❑ 5. Smooth/Cleanable <br /> ❑ ❑ 6. Covin <br /> ❑ 7. Cleaning Frequency <br /> Structure Operation Walls <br /> ❑ ❑ 8. Smooth/Cleanable <br /> ❑ ❑ 1 9. Cleaning Frequency <br /> Structure Operation Cages <br /> ❑ ❑ 10. Condition <br /> ❑ 11. Sanitation <br /> Structure Operation Food <br /> ❑ ❑ 12. Storage <br /> ❑ F1 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 REE,IVED gY INS CTOR <br /> ❑ ❑ 18. Certificate on Premises ` l 1 <br /> VECTOR411- <br /> CONTROL INSPECTION FORM <br /> EHD 40-06 4/6/12 <br /> Page_of <br />