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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />304 East Weber Avenue, 3`d Floor, Stockton, CA 95202-2708 <br />Telephone: (209) 468-3420 Fax: (209) 464-0138 Web: www.sjgov.org/ehd <br />q�t�O:R�j <br />VECTOR CONTROL INSPECTION FORM <br />EHD 40-06 6/30/2005 /-/ Page _ f <br />POULTRY RANCH <br />DBA <br />INSPECTION DATE <br />Structure <br />Operation <br />Water Well <br />96S <br />❑ <br />❑ <br />1. Well struction <br />PREMISE ADDRESS <br />REINSPECTION DATE <br />❑ <br />❑ <br />2. Cross -Connection <br />1 <br />Structure <br />Operation <br />Manure Management <br />OWNER/OPERATOR <br />PHONE <br />❑ <br />❑ <br />3. Spreading and Disking <br />❑ <br />❑ <br />4. Concrete Tanks <br />INSPECTION TYPE <br />PROGRAM ELEMENT <br />RECORD ID <br />❑ <br />❑ <br />5. Lagooning5' <br />❑ <br />❑ <br />6. Composting <br />The items b low represent code violations and must be corrected: <br />Structure <br />Operation <br />Bird DISpOSaI <br />❑ <br />❑ <br />7. Burying with 2" of Cover <br />❑ <br />❑ <br />8. Approved Concrete Tank <br />❑ <br />❑ <br />9. Removal from Premises <br />1 <br />Structure <br />Operation <br />Vector Control <br />❑ <br />❑ <br />10. Domestic Fl <br />❑ <br />❑ <br />11. Fannia Fl <br />❑ <br />❑ <br />12. Larvae <br />❑ _ <br />❑ <br />13. Pupae <br />El❑ <br />14. Adult <br />r <br />%r <br />❑ <br />❑ <br />15. Light Po ulatio <br />❑ <br />❑ <br />16. Moderate ulation <br />❑ <br />❑ <br />17. Heavy opulation <br />Structure <br />Operation <br />Feeding/Water <br />❑ <br />❑ <br />18. Water Troughs <br />❑ <br />❑ <br />19. Cups or Bowls <br />❑ <br />❑ <br />20. Food Storage <br />Structure <br />Operation <br />Houses <br />❑ <br />❑ <br />21. Floors <br />❑ <br />❑ <br />22. Walls/Ceilings <br />❑ <br />❑ <br />23. Cleaning Frequency <br />KENNEL <br />1 NIA <br />e - <br />Structure <br />Operation <br />Water Well <br />m <br />❑ <br />❑ <br />1. Well Construction <br />❑ <br />❑ <br />2. Cross Connection <br />Structure <br />Operation <br />Floors <br />❑ <br />❑ <br />3. Properly Graded to <br />❑ <br />❑ <br />4. Drain <br />❑ <br />❑ <br />5. Smooth/Cleanable <br />❑ <br />❑ <br />6. Covin <br />a <br />-� <br />❑ <br />❑ <br />7. Cleaning Frequency <br />Structure <br />Operation <br />Walls <br />❑ <br />❑ <br />8. Smooth/Cleanable <br />❑ <br />❑ <br />9. Cleaning Frequency <br />Structure <br />Operation <br />Cages <br />❑ <br />❑ <br />10. Condition <br />❑ <br />❑ <br />11. Sanitation <br />Structure <br />Operation <br />Food <br />❑ <br />❑ <br />12. Storage <br />❑ <br />❑ <br />13. Insect/Vermin <br />Structure <br />Operation <br />Animal Disposal <br />❑ <br />❑ <br />14. Removal from Premises <br />❑ <br />❑ <br />15. Other <br />Structure <br />Operation <br />Sewage Disposal <br />❑ <br />❑ <br />16. Septic System <br />❑ <br />❑ <br />17. Sewer . <br />Structure <br />Operation <br />Rabies Vaccination <br />I RECEIVED BY <br />INSP T(iR <br />/ <br />I <br />❑ <br />❑ <br />18. Certificate on Premises <br />EHD 40-06 6/30/2005 /-/ Page _ f <br />