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SAN JOAQUIN COUNTY <br /> A <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, California 95205-6232 <br /> �q. ....•;e Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd <br /> LlpC) <br /> VECTOR CONTROL INSPECTION FORM <br /> DBA INSP CTION DATE <br /> Structure Operation <br /> ❑ ❑ 1. Well Construction PREMISE ADDRESS RE-INSPECTION DATE <br /> ❑ ❑ 2. Cross-Connection <br /> Structure Operation Manure Mana ement OWNER/OPERATOR PHONE <br /> ❑ ❑ 3. Spreading and Disking 96`�'-j,(Z 6W CJ <br /> El 4. Concrete Tanks INSPECTION TYPE PROGRAM ELEMENT RECORD ID <br /> El ❑ 5. Lagooning j 0 (1 <br /> -03 <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 74W <br /> Structure Operation Vector Control <br /> ❑ ❑ 10. Domestic FI <br /> ❑ El 11. Fannia FI <br /> ❑ ❑ 12. Larvae Q <br /> ❑ ❑ 13. Pupae <br /> ❑ ❑ 14. Adult <br /> ❑ ❑ 15. Light Population <br /> ❑ ❑ 16. Moderate Population E? AN G <br /> ❑ ❑ 17. Heavy Population <br /> Structure Operation Feeding/Water Aa , <br /> Qe <br /> ❑ ❑ 18. Water Troughs <br /> ❑ ❑ 1 19. Cups or Bowls <br /> 20. Food Storage <br /> Structure Operation Houses S <br /> ❑ ❑ 21. Floors <br /> ❑ ❑ 22. Walls/Ceilings Im C, n <br /> ❑ ❑ 23. CleaningRAFre uenc <br /> �'�' t�O <br /> rStructureOpeLration Water Well <br /> 1. Well Construction <br /> 2. Cross Connectionion Floors <br /> ❑ El 3. Properly Graded to Sewer <br /> ❑ ❑ 4. Drain JL ••�• <br /> ❑ ❑ j 5. Smooth/Cleanable 11 <br /> ❑ ❑ 6. oving47, <br /> El 7. Cleaning Frequency <br /> Structure Operation Walls <br /> ❑ ❑ 8. Smooth/Cleanable <br /> ❑ ❑ 9. Cleaning Frequency X t S <br /> Structure Operation Cages <br /> ❑ ❑ 10. Condition r K <br /> 11. Sanitation <br /> Structure Operation Food <br /> ❑ ❑ 12. Storage <br /> ❑ 13. Insect/Vermin <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 RECEIVEDB IN T <br /> i <br /> ❑ ❑ 18. Certificate on Premises <br /> VECTOR CONTROL INSPECTION FORM <br /> Pageof <br /> EHD 40-06 4/6/12 f�r <br /> ' '� <br />