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PQ u i" SAN JOAUIN COUNTY ®G ENVIRONMENTAL HEALTH DEPARTME 304 East Weber Avenue, 3`d Floor, Stockton,CA 95202-2708 Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd VECTOR CONTROL INSPECTION FORM POULTRY RANCH DBA INSPECTION DATE Structure Operation Water Well ❑ El 1. Well Construction PREMISE ADDRESS REINSPECTION DATE ❑ ❑ 2. Cross-Connection s- ,. Structure Operation Manure Management OWNE E PHONE ❑ ❑ 3. Spreading and Disking Ro l per, ❑ El 4. Concrete Tanks INSPECTION TYPE l PROGRAM ELEMENT RECORD ID ❑ E3 5. Lagooning I e,i ❑ ❑ 6. Composting The items Below represent code violations and must be corrected: Structure Operation Bird Disposal ❑ ❑ 7. Burying with 2"of Cover ❑ ❑ 8. Approved Concrete Tank / 1:19. Removal from Premises ra j e9 ,,T be- Structure Operation Vector Control ❑ El 10. Domestic FI ❑ ❑ 11. Fannia Fl ❑ 12. Larvae 13. Pu ae j ❑ El 14. Adult lAj(r amt l fS O ❑ 0 15. Light Population ❑ ❑ 16. Moderate Population D ❑ ❑ 17. Heavy Population Structure Operation Feeding/Water ❑ ❑ 18. Water Troughs s ❑ 19. Cups or Bowls ) u y ❑ El 20. Food Storage Structure Operation Houses S - ❑ ❑ 21. Floors ❑ El 22. Walls/Ceilings ❑ ❑ 23. Cleaning Fre uenc r e KENNEL tJ ' 4� l Structure Operation Water Well ❑ ❑ 1. Well Construction ❑ El 2. Cross Connection L:3) A Structure Operation Floors h ❑ ❑ 3. Properly Graded to s ❑ ❑ 4. Drain w- ❑ ❑ 5. Smooth/Cleanable ❑ ❑ 6. Covin o t ❑ ❑ 7. Cleaningrequency 1i c Structure Operation Walls ( t , LA 51.1- n ❑ 8. Smooth/Cleanable ❑ El 9. Cleaning Frequency t Structure Operation Cages / P ❑ ❑ 10. Condition ❑ ❑ 11. Sanitation Structure Operation Food ❑ 12. Storage ❑ ❑ 13. Insect/Vermin Structure Operation Animal Disposal ❑ 14. Removal from Premises 15. Other Structure Operation Sewage Disposal ❑ El 16. Septic System ❑ 0 17. Sewer Structure Operation Rabies Vaccination RECEIVED BY // INSPECT ❑ ❑ 18. Certificate on Premises to EHD 40-06 6/30/2005 Page 4Of