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"' <br /> " SAN JOAQUIN COUNTY <br /> a° eo` <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street Stockton, CA 95202-3029 <br /> �� Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd <br /> �1FOR <br /> VECTOR CONTROL INSPECTION FORM <br /> DSA INSPEC NDA E <br /> Structure Operation41 1 <br /> ❑ ❑ 1. Well Construction PREMISE ADDRESS E-IN P C N DATE <br /> ❑ ❑ 2. Cross-Connection IL <br /> Structure Operation Manure Management OWNER/® TOP O E <br /> ❑ ❑ 3. Spreading and Disking r <br /> ❑ ❑ 4. Concrete Tanks CPE PROGRAM ELEME T RE ORD ID loe <br /> ❑ ❑ 5. Lagooning <br /> ❑ ❑ 6. Composting The items below represent code violatians and mast be correcte <br /> Structure Operation Bird Disposal <br /> ❑ ❑ 7. Burying with 2"of Cover w <br /> ❑ ❑ 8. Approved Concrete Tank <br /> ❑ ❑ 1 9. Removal from Premises <br /> Structure Operation Vector Control <br /> ❑ ❑ 10. Domestic FI <br /> 11. Fannia FI <br /> ❑ ❑ 12. Larvae i <br /> ❑ ❑ 13. Pupae <br /> ❑ 1 14. Adult eAAr <br /> ❑ ❑ 15. Light Population <br /> ❑ ❑ 16. Moderate Population <br /> ❑ ❑ 17. Heavy Population <br /> Structure Operation Feeding/Water <br /> ❑ ❑ 18. Water Troughs <br /> ❑ ❑ 1 19. Cups or Bowls 0 El <br /> 20. Food Storage <br /> Structure Operation Houses <br /> ❑ ❑ 21. Floors <br /> ❑ ❑ 22. Walls/Ceilings <br /> ❑ ❑ 23. Cleanin Fre I <br /> uencil. 7.s 0I s <br /> Structure Operation Water Well /a <br /> ❑ ❑ 1. Well Cons ction <br /> 13 2. Cross Co nection <br /> Structure Operation Floors <br /> ❑ ❑ 3. Prope Graded to Sewer <br /> ❑ ❑ 4. Drai <br /> ❑ 5. S th/Cleanable <br /> 6. vin <br /> El 'So 7. $leaning Frequency <br /> Structure Op.;NonVyblls ~` <br /> ❑ ❑ Smooth/Cleanable <br /> ❑ ❑ 9. eaning Frequency <br /> Structure Operation Cag <br /> ❑ ❑ 10. Con kion <br /> 11. Sanitati n <br /> Structure Operati Food <br /> ❑ ❑ 12. Storage <br /> 0 01 13. InsecWermin <br /> Structure Ope on Animal Dis al <br /> ❑ 14. Removal from Premises <br /> ❑ 15. Other <br /> Structure operation Sewage Disposal <br /> ❑ ❑ 16. Septic System <br /> ❑ ❑ 17. Sewer <br /> StructureOperAtion Rabies Vaccination RECEI ED BY INSPECT ` <br /> L <br /> ❑ El18. Certificate on Premises <br /> VECTOR CONTROL INSPECTION FORM <br /> EHD 40-06 12/04/08 <br /> Page_of_ <br />