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SAN JOAQUIN COUNTY <br /> �J <br /> N <Z ENVIRONMENTAL HEALTH DEPARTMENT <br /> `. 1868 East Hazelton Avenue, Stockton, California 95205-6232 <br /> Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd <br /> �IppR <br /> VECTOR CONTROL INSPECTION FORM <br /> DBA INSPECTION DATE <br /> Structure Operation - - <4E3 ❑ 1. Well Construction PREMISE ADDRESS RE-INSPECTION DATE <br /> ❑ ❑ 2. Cross-Connection <br /> -7 - <br /> Structure Operation Manure Management WNER/OPERATOR PHONE <br /> ❑ ❑ 3. Spreading and Disking <br /> F <br /> ❑ ❑ 4. Concrete Tanks INSPECTION TYPE PROGRAM ELEMENT RECORD ID <br /> ❑ ❑ 5. Lagooning <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 �(�iL/ <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 //��ii <br /> U <br /> 1:1 El 14. Adult rr <br /> En <br /> ❑ ❑ 15. Light Population <br /> ❑ ❑ 16. Moderate Population \ C \ <br /> ❑ ❑ 17. Heavy Population <br /> Structure Operation Feeding/Water t -� <br /> ❑ ❑ 18. Water Trou hs ff <br /> ❑ ❑ 19. Cups or Bowls �2- <br /> 20. Food Storage <br /> Structure Operation Houses 0' rf- ..S <br /> iA <br /> El E] 21. Floors / <br /> ❑ ❑ 22. Walls/Ceilings A ` <br /> ❑ ❑ 23. Cleanin Fre uenc <br /> :XENNE4311111111119111IMMUM1 <br /> Structure Operation I Water Well <br /> ❑ ❑ 1. Well Construction <br /> El 2. Cross Connection <br /> Structure Operation Floors V L y\A. <br /> ❑ ❑ 3. Properly Graded to Sewer <br /> ❑ ❑ 4. Drain <br /> ❑ ❑ 5. Smooth/Cleanable <br /> ❑ ❑ 6. Covin 1. s <br /> ❑ El 7. Cleaning Frequency <br /> Structure Operation Walls 1/\ p�`� i�L C <br /> ❑ ❑ 8. Smooth/Cleanable 1 <br /> ❑ ❑ 9. Cleaning Frequency r : ) Zza <br /> Structure Operation Cages <br /> ❑ ❑ 10. Condition A4S S <br /> El El 11. Sanitation <br /> Structure Operation Food fj <br /> ❑ ❑ 12. Storage <br /> El El 13. insect/vermin Z <br /> Structure Operation Animal Disposal <br /> ❑ ❑ 14. Removal from Premises <br /> ❑ ❑ 15. Other <br /> Structure Operation Sewage Disposal <br /> ❑ ❑ 16. Septic System <br /> ❑ ❑ 17. Sewer <br /> Structure Operation Rabies Vaccination RECEI E BY INSPECT <br /> 1:1 E] 18. Certificate on Premises <br /> VECTOR CONTROL INSPECTION FORM <br /> EHD 40-06 4/6/12 L <br /> Page_of <br />