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,oRQu�" .gip SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 East Hazelton Avenue, Stockton, California 95205-6232 <br />coq.: ;...;Q • Telephone: (209) 468-3420 Fax: (209) 464-0138 Web: www.sjgov.org/ehd <br />�r�oRN <br />VECTOR CONTROL INSPECTION FOR <br />DBA INS <br />CTION DATE <br />Structure Operation Water Well $. <br />❑ ❑ 1. Well Construction PREMISE ADDRESS RE-INSPECTION DATE <br />❑ ❑ 2. Cross-Connection t <br />Structure Operation Manure Management OWNER/OPERATOR PHONE <br />❑ ❑ 3. Spreading and Disking 'ti <br />❑ ❑ 4. Concrete Tanks INSPECTION TYPE PROGRAM ELEMENT RECORD ID <br />❑ ❑ 5. Lagooning <br />❑ ❑ 6. Composting T e items below represent code violations and must be corrected: <br />Structure Operation Bird Disposal <br />❑ ❑ 7. Burying with 2" of Cover 7 . <br />❑ ❑ 8. Approved Concrete Tank <br />❑ ❑ 9. Removal from Premises S Id Ag> <br />Structure Operation Vector control <br />❑ ❑ 10. Domestic FI <br />11. Fannia FI <br />❑ ❑ 12. Larvae t <br />❑ ❑ 13. Pupae <br />❑ ❑ 1 14. Adult <br />❑ ❑ 15. Light Population <br />❑ ❑ 16. Moderate Population S <br />❑ ❑ 17. Heavy Population <br />Structure Operation Feeding/Water <br />❑ ❑ 18. Water Troughs <br />❑ ❑ 19. Cups or Bowls <br />20. Food Storage <br />Structure Operation Houses <br />❑ ❑ 21. Floors <br />❑ ❑ 22. Walls/Ceilings k <br />❑ ❑ 23. Cleanin Fre uenc 0 <br />21MM 14 <br />Structure Operation Water Well <br />❑ ❑ 1. Well Construction <br />2. Cross Connection <br />Structure Operation Floors <br />3. Pro erl Graded to Sewer <br />❑ ❑ 4. Drain <br />❑ ❑ 5. Smooth/Cleanable <br />6. Covin <br />El 0 7. Cleaning Frequency <br />Structure Operation Walls <br />❑ ❑ 8. Smooth/Cleanable <br />❑ ❑ 9. Cleaning Frequency <br />Structure Operation cages <br />❑ ❑ 10. Condition <br />El 11. Sanitation <br />Structure Operation Food <br />❑ ❑ 12. Storage <br />13. insecWermin <br />Structure Operation Animal Disposal <br />❑ ❑ 14. Removal from Premises <br />❑ ❑ 15. Other <br />Structure Operation Sewage Disposal <br />❑ ❑ 1 16. Septic System p <br />❑ ❑ 17. Sewer <br />Structure Operation Rabies Vaccination RECEIVE . Y JINSPECTOR <br />❑ ❑ 18. Certificate on Premises <br />VECTOR CONTROL INSPECTION FORM <br />EHD 40-06 4/6/12 <br />Page _ of _ <br />