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low SAN JOA UIN COUNTY ' X ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street Stockton, CA 95202-3029 Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd �rFOR VECTOR CONTROL INSPECTION FORM DBA INSPECTION DATE Structure Operation Y /6 ❑ ❑ 1. Well Construction PREMIS DRESS i RE-INSPECTION DATE ❑ ❑ 2. Cross-Connection Structure Operation Manure Management OWNER/OPERATOR PHONE ❑ ❑ 3. Spreading and DiskingMkYN QUA ,( ❑ ❑ 4. Concrete Tanks INS N TYPE PROGRAM ELEMENT RECORD ID ❑ 5. Lagooning S ❑ ❑ 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 ❑ ❑ 9. Removal from Premises Structure Operation vector Control ❑ ❑ 10. Domestic FI 11. Fannia FI ❑ ❑ 12. Larvae ❑ ❑ 13. Pupae ❑ ❑ 14. Adult ❑ ❑ 15. Light Population ❑ ❑ 16. Moderate Population ❑ ❑ 17. Heavy Population Structure Operation Feeding/Water ❑ ❑ 18. Water Troughs ❑ ❑ 19. Cups or Bowls 20. Food Stora Structure Operation Houses ❑ ❑ 21. Floors ❑ ❑ 22. Walls/Ceilings s ❑ ❑ 23. Cleanin Fr uenc sen, re Operation Water Well ❑ ❑ 1. Well Construction r] 171 2. Cross Connection Structure Operation Floors ❑ ❑ 3. ProerlGraded to Sewer ❑ 4. Drain j ❑ 5. Smooth/Cleanable a ❑ 6. Coving r 11 ❑ 7. Cleaning Frequency Structure Operation Walls ❑ ❑ Smooth/Cleanable ❑ ❑ 9\Cleaning Frequency Structure Operation CabPS ❑ ❑ 10. Andition 11. Sa 'tation Structure Operation Food ❑ ❑ 12. Stora 13. Ins renin Structure Operation Animal Di oral ❑ ❑ 14. Removal Premises ❑ ❑ 15. Other Structure Operation Sewage Dispo al ❑ ❑ 1 16. Septic S tem ❑ ❑ 17. Sewer Structure OperAtion Rabies VaccinatioA INSPEC R ❑ ❑ 18. Certificate on Premises VECTOR CONTROL INSPECTION FORM EHD 40-06 12/04/08 Page_of