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SAN OAQUIN COUNTY r., G E ONMENTAL HEALTH DEPARTAT 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^ INSPECTI A Structure Operation Water Well ❑ ❑ 1. Well Construction PREMISE ADDRESS REINSAE&ICA DATE ❑ ❑ 2. Cross-Connection ® 1 Structure Operation Manure Management OWNER/ PERATOR P ONE ❑ ❑ 3. Spreading and Disking I ❑ ❑ 4. Concrete Tanks INSP TION PE PROG LEMENT ORD I 11 E] 5. Lagooning ❑ ❑ 6. Composting The items below represent code violations and must be corrected: Structure Operation Bird Disposal 1 ❑ ❑ 7. Burying with 2"of Cover 3 ❑ ❑ 8. Approved Concrete Tank / r/ ❑ ❑ 9. Removal from Premises Structure Operation Vector Control ❑ ❑ 10. Domestic FI ❑ ❑ I1. Fannia FI ❑ ❑ 12. Larvae I tj a-, AAx 1� / )/if AIJ4" �6 ❑ 0 13. Pupae ❑ ❑ 14. Adult 11 El 15. Li ht Po ulation ❑ ❑ 16. Moderate Population ® e ❑ ❑ 17. Heavy Population Structure Operation Feeding/Water ❑ ❑ 18. Water Trou hs ❑ ❑ 19. Cups or Bowls ❑ ❑ 20. Food Storage l Structure Operation Houses ❑ ❑ 1 21. Floors ❑ ❑ 22. Walls/Ceilings ❑ ❑ 23. Clea ninE Fre uenc , KENNEL Structure Operation Water Well ❑ ❑ 1. Well Construction ❑ ❑ 2. Cross Connection 1 Structure Operation Floors ❑ 3. Properly Graded to ❑ El 4. Drain ❑ ❑ 5. Smooth/Cleanable ❑ ❑ 6. Covin ❑ ❑ 7. Cleaning Frequency Structure Operation Walls ❑ ❑ 8. Smooth/Cleanable 1 El9. Cleaning Fre uenc 1 Structure Operation Cages Apnb ❑ ❑ 10. Condition S ❑ ❑ 11. Sanitation Structure Operation Food ❑ 12. Storage , 1 ❑ El 13. Insect/Vermin 7 Structure Operation Animal Disposal ❑ ❑ 14. Removal from Premises ❑ ❑ 15. Other Structure Operation Sewage Disposal ❑ ❑ 16. Septic System ❑ 17. Sewer Structure Operation Rabies Vaccination RECEIVED BY < INSP T R ❑ ❑ 18. Certificate on Premises EHD 40-06 6/30/2005 Page_of_