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0. V 1N SAN JOAQUIN COUNTY • <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202-2708 <br />c. <br />Telephone: (209) 468-3420 Fax: (209) 464-0138 Web: www.sjgov.org/ehd <br />q 1 <br />FO <br />VECTOR CONTROL INSPECTION FORM <br />EHD 40-06 6/30/2005 `-..1 • � -1/f // Page ofd <br />POULTRY RANCH <br />DBA C� <br />S <br />►i g <br />INSPECTION DATE <br />.,_,7 <br />Structure Operation I Water Well <br />❑ <br />1. Well Construction <br />PREMISE ADDRESS <br />f* <br />c. <br />RFINSPFCTION DATE <br />G7 �e`� <br />❑ ❑ 2. Cross -Connection <br />Structure <br />Operation <br />Manure Management <br />OWNE QPERATOR <br />/�`` <br />PHONE <br />;201- L[0, <br />11 E]3. Spreading and Disking <br />❑ <br />❑ <br />4. Concrete Tanks <br />INSPE TION TYPE <br />i L' Tlkvld- <br />ROGRAM ELEMENT <br />RECORD ID <br />I p KE j= <br />❑ ❑ 5. Lagooning <br />❑ <br />❑ <br />6. Composting <br />The items below represent code violations and must be corrected: <br />Structure <br />Operation <br />Bird Disposal <br />❑ ❑ 7. Burying with 2" of Cover <br />❑ <br />❑ <br />8. Approved Concrete Tank <br />f� ✓ <br />C" <br />❑ ❑ 9. Removal from Premises <br />Structure <br />Operation <br />Vector Control <br />_ �' <br />❑ ❑ 10. Domestic FI <br />❑ <br />❑ <br />11. Fannia FI <br />❑ ❑ 12. Larvae <br />❑ <br />❑ <br />13. Pupae <br />❑ ❑ 14. Adult <br />❑ <br />❑ <br />15. Light Population <br />❑ ❑ 16. Moderate Population <br />❑ <br />17. Heavy Population <br />�- � �' <br />- 1 <br />Structure Operation Feeding/Water <br />❑ <br />❑ <br />18. Water Troughs <br />kryelc tx <br />❑ ❑ 19. Cups or Bowls <br />❑ <br />❑ <br />20. Food Storage <br />- <br />R <br />Structure Operation Houses <br />❑ <br />❑ <br />21. Floors <br />❑ ❑ 22. Walls/Ceilings <br />❑ <br />❑ <br />23. Cleaning Frequency <br />KENNEL <br />Structure <br />operation <br />Water Well <br />❑ ❑ 1. Well Construction <br />❑ <br />❑ <br />2. Cross Connection <br />Structure Operation Floors <br />❑ <br />❑ <br />3. Properly Graded to <br />❑ ❑ 4. Drain <br />❑ <br />❑ <br />5. Smooth/Cleanable <br />If <br />❑ ❑ 6. Covin <br />❑ <br />❑ <br />7. Cleaning Fre uenc <br />-�- <br />Structure Operation Walls <br />❑ <br />❑ <br />8. Smooth/Cleanable <br />�v " d -z-- <br />❑ ❑ 9. Cleaning Fre uenc <br />Structure <br />Structure <br />Operation <br />Cages <br />❑ ❑ 1 10. Condition <br />❑ <br />❑ <br />I 11. Sanitation <br />Structure Operation Food <br />❑ <br />❑ <br />12. Storage <br />❑ ❑ 13. InsectfVermin <br />Structure <br />Operation <br />Animal Disposal <br />❑ ❑ 14. Removal from Premises <br />❑ <br />❑ <br />15. Other <br />Structure Operation I Sewage Disposal <br />❑ <br />❑ <br />16. Septic System <br />❑ ❑ 17. Sewer <br />Structure <br />Operation <br />Rabies Vaccination <br />RECEIV BY <br />IN OR <br />f ` <br />❑ ❑ 18. Certificate on Premisesak, <br />EHD 40-06 6/30/2005 `-..1 • � -1/f // Page ofd <br />