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PQuiN SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> :X <br /> 1868 East Hazelton Avenue, Stockton, California 95205-6232 <br /> • aq.. :...;P• Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd <br /> C/PpRN ® �® ® p® <br /> VECTOR CONTROL INSPECTION FORM <br /> DBA INS ECTION DATE <br /> Structure Operation <br /> ❑ ❑ 1. Well Construction PREMISEADDRESS RE-INSPECTION DATE <br /> 1:1 ❑ 2. Cross-Connection " <br /> Structure Operation Manure Mana eent NE OPER mPHONE <br /> El ❑ 3. Spreading and Disking <br /> ❑ ❑ 4. Concrete Tanks IN PE TION TYPE PROGRAM ELEMENT RECORD ID <br /> E] ❑ 5. Lagooning r� <br /> ❑ ❑ 6. Composting The items below represent code violations and must be corrected: <br /> Structure Operation Bird Disposal <br /> ❑ ❑ 7. Burying with 2"of Cover <br /> ❑ ❑ 8. Approved Concrete Tank <br /> ❑ ❑ 9. Removal from Premises <br /> Structure operation Vector Control <br /> ❑ ❑ 10. Domestic FI <br /> 11. Fannia FI <br /> ❑ ❑ 12. Larvae <br /> ❑ ❑ 13. Pupae <br /> ❑ ❑ 14. Adult e <br /> ❑ ❑ 15. Light Population 1 <br /> ❑ ❑ 16. Moderate Population MrAklAzicr, lip <br /> ❑ ❑ 17. Heavy Population <br /> Structure Operation Feeding/Water <br /> ❑ ❑ 18. Water Troughs <br /> ❑ ❑ 19. Cups or Bowls <br /> El 20. Food Storage <br /> Structure Operation Houses P <br /> ❑ ❑ 21. Floors <br /> ❑ ❑ 1 22. Walls/Ceilings CAI Aa On� <br /> ❑ ❑ 23. Cleanin Fre uenc <br /> Structure operation Water Well <br /> ❑ ❑ 1. Well Construction eyy <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 ! I <br /> 7. Cleaning Fre uenc <br /> Structure Operation Walls r I, ` Y <br /> ❑ ❑ 8. Smooth/Cleanable <br /> ❑ ❑ 1 9. Cleaning Frequency <br /> Structure Operation Cages <br /> ❑ ❑ 10. Condition V <br /> 11. Sanitation <br /> Structure Operation Food <br /> ❑ ❑ 12. Stora e <br /> 13. Insect/Vermin <br /> Structure Operation Animal Disposal <br /> ❑ ❑ 14. Removal from Premises '20VY5 Le <br /> ❑ ❑ 15. Other <br /> Structure operation Sewage Disposal Ft <br /> ❑ ❑ 16. Septic System <br /> ❑ ❑ 17. Sewer <br /> Structure Operation Rabies Vaccination RE VED INSPECT � Ll <br /> ❑ ❑ 18. Certificate on Premises j <br /> VECTOR CONTROL INSPECTION FORM <br /> EHD 40-06 4/6/12 <br /> Page_ f_ <br />