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f <br /> U'N SAMk <br /> AN JOAQUIN COUNTY <br /> _ EN IRONMENTAL HEALTH DEPARTMENT <br /> 304 East Weber Avenue,3rd Floor, Stockton, CA 95202-2708 <br /> Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sigov.org/ehd <br /> Cq\F_d R��P <br /> VECTOR CONTROL INSPECTION FORM <br /> POULTRY RANCH DBA INSPE TION ATE <br /> Structure Operation Water Well ® V, <br /> ❑ ❑ 1. Well Construction PREMISE ADDRESS REINSP CTI N DATE <br /> ❑ 2. Cross-Connection -L & L a, ."L, <br /> Structure Operation Manure Management OWNERIOPERATOR PHONE <br /> ❑ ❑ 3. Spreading and Disking L <br /> ❑ 4. Concrete Tanks INSPECTION E i PROGRAM ELEMENT RECORD ID <br /> ❑ ❑ 5. Lagooning VCC1,1200-LAS- 'kt� &4ilk <br /> ❑ ❑ 6. Composting The items below represent code violations and must be correcte <br /> Structure Operation Bird Disposal <br /> ❑ ❑ 7. Burying with 2"of Cover <br /> ❑ ❑ 8. ApprovedConcrete Tank <br /> ❑ ❑ 9. Removal from Premises <br /> Structure Operation Vector Control ` <br /> 11 10. Domestic FI - L t'� L 5 t <br /> ❑ 0 11. Fannia Fl <br /> ❑ El 12. Larvae l? 6 .� <br /> ❑ ❑ 13. Pupae <br /> ❑ ❑ 14. Adult > t`5 �i � �! <br /> ❑ ❑ 15. Light Population <br /> ❑ ❑ 16. Moderate Population L�9 w �� �°"`� d c. <br /> ❑ ❑ 17. Heavy Population <br /> Structure Operation Feeding/Water `v4 C t <br /> ❑ El 18. Water Troughs <br /> ❑ ❑ 19. Cups or Bowls 'd ®`5 L- ! C^ -'e- tli LA, <br /> ❑ ❑ 20. Food Stora e <br /> Structure Operation Houses -C Z>U-4' <br /> ❑ ❑ 21. Floors <br /> ❑ ❑ 22. Walls/Ceilings <br /> ❑ ❑ 23. Cleaning Fre uenc t <br /> KENNEL ~tt�r � v �Gc,cv <br /> Structure Operation Water Well �. <br /> r� g <br /> ❑ El 1. Well Construction 1 <br /> ❑ 11 2. Cross Connection <br /> Structure Operation Floors L�l L •. �O `tet <br /> ❑ 3. Properly Graded to <br /> ❑ ❑ 4. Drain S1r.5 <br /> ❑ ❑ 5. Smooth/Cleanable <br /> ❑ ❑ 6. Covin (A i <br /> ❑ ❑ 7. Cleanin Frequency 1\1 <br /> Structure Operation Walls 0 <br /> ❑ ❑ 8. Smooth/Cleanable <br /> ❑ 9. Cleanin Fre uenc D 'rL - <br /> Structure Operation Cages <br /> ❑ ❑ 10. Condition <br /> ❑ ❑ 11. Sanitation <br /> Structure Operation Food <br /> 11 El 12. StoraLe <br /> ❑ 0 13. Insect/Vermin cx. - t <br /> Structure Operation Animal Disposal <br /> ❑ ❑ 14. Removal from Premises <br /> ❑ El 15. Other t <br /> Structure operation Sewage Disposal O m-0.� <br /> ❑ 0 16. Septic System <br /> ❑ ❑ 17. Sewer <br /> Structure operation Rabies Vaccination RECEIVED BY IN CTO <br /> El 1:1 18. Certificate on Premises <br /> EHD 40-06 6/30/2005 Page_of_ <br />