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Pa t, t <br />SAN JOAQUIN COUNTY <br />a <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />304 East Weber Avenue, 3`d Floor, Stockton, CA 95202-2708 <br />�.. <br />Telephone: (209) 468-3420 Fax: (209) 464-0138 Web: www.sjgov.org/ehd <br />�Ft7R <br />VECTOR CONTROL INSPECTION FORM <br />POULTRY RANCH DBA <br />INSPECTION DATE <br />Structure <br />Operation <br />Water Well <br />❑ <br />❑ <br />1. Well Construction PREMISE ADDRESS <br />INSPE OND TE <br />❑ <br />❑ <br />2. Cross-Connection , -� <br />�4 <br />Structure <br />Operation <br />Manure Management OWN OPERATOR <br />PHONE <br />❑ <br />❑ <br />3. Spreading and Disking t 1 <br />` ' <br />❑ <br />❑ <br />4. Concrete Tanks INSPECTION TYPE <br />PROGFAM ELEMENT <br />RECORD ID <br />❑ <br />❑ <br />5. Lagooning9 <br />Cl <br />❑ <br />6. Composting The items Wow represent code violations and must be Corrected: <br />Structure <br />Operation <br />Bird Disposal <br />❑ <br />❑ <br />7. Burying with 2" of Cover <br />❑ <br />❑ <br />8. Approved Concrete Tank <br />❑ <br />❑ <br />9. Removal from Premises7f1 <br />Structure <br />Operation <br />Vector Control <br />❑ <br />❑ <br />10. Domestic Fl ht^ <br />❑ <br />❑ <br />11. Fannia FI <br />❑ <br />❑ <br />12. Larvae <br />❑❑ <br />0 <br />El <br />13. Pu ae / t / <br />t%Ave. <br />14. Adult (/ / 114.5(-e <br />❑ <br />❑ <br />15. Light Population <br />❑ <br />❑ <br />16. Moderate Population i . <br />r <br />7 +75 <br />❑ <br />1 ❑ <br />17. Heavy Population <br />Structure <br />Operation <br />Feeding/Water <br />h <br />t <br />1 . <br />11 <br />18. Water Troughs <br />❑ <br />❑ <br />19. Cups or Bowls <br />❑ <br />❑ <br />20. Food StoraLe <br />Structure <br />Operation <br />Houses <br />❑ <br />❑ <br />21. Floors <br />❑ <br />❑ <br />22. Walls/Ceilings <br />❑ <br />23. Cleaning Fre uenc <br />KENNEL <br />Structure <br />Operation <br />Water Well <br />❑ <br />❑ <br />1. Well Construction <br />❑ <br />❑ <br />2. Cross Connection <br />Structure <br />Operation <br />Floors <br />❑ <br />3. Properly Graded to <br />11 <br />❑ <br />4. Drain <br />❑ <br />El5. <br />Smooth/Clearlble <br />❑ <br />❑ <br />6. Covin <br />❑ <br />❑ <br />7. Cleanitt re uenc <br />Structure <br />Operation <br />alls <br />❑ <br />0 <br />8. Sm th/Cleanable <br />❑ <br />El <br />9. Waning Frequency <br />Structure <br />Operation <br />C e <br />❑ <br />El <br />A Co dition <br />❑ <br />❑ <br />11. Sant tion <br />Structure <br />Operation <br />Food <br />❑ <br />❑ <br />12. Stora e <br />❑ <br />EY <br />13. Insect/Ve in <br />Structure <br />Ope tion <br />Animal Dlspo I <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 RECEIVE INSPECTO <br />❑ <br />18. Certificate on Premises <br />EHD 40-06 <br />6/30/2005 <br />Page Of <br />