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SAN JOAQUIN COUNTY A ENVIRONMENTAL HEALTH DEPARTMENT N 1868 East Hazelton Avenue, Stockton, California 95205-6232 �q., ....;P Telephone:(209)468-3420 Fax.(209)464-0138 Web:www.sjgov.org/ehd ��FORN VECTOR CONTROL INSPECTION FORM DBA CIN ECTION DATE Structure Operation I WaterWell S ❑ ❑ 1. Well Construction PREMISE ADDRESS RE-INSPECTION DATE ❑ ❑ 2. Cross-Connection g,its, S Structure Operation Manure management OWNER/OPERATOR PHONE ❑ ❑ 3. Spreading and Disking r ❑ ❑ 4. Concrete Tanks INSP CTION TYPE PROGRAM ELEMENT RECORD ID ❑ ❑ 1 5. Lagooning m ❑ ❑ 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 35 n 11. Fannia FI ❑ ❑ 12. Larvae 1 ❑ ❑ 13. Pupae ❑ ❑ 14. Adult ❑ ❑ 15. Light Population I ` El 1:116. Moderate Population �- ❑ ❑ 17. Heavy Population Structure Operation Feeding/Water ❑ ❑ 18. Water Troughs ❑ ❑ 19. Cups or Bowls + 20. Food Storage Structure Operation Houses t.- 4 Xn� Tr 4rr,Cc_jZ e-N) ❑ ❑ 21. Floors ❑ ❑ 22. Walls/Ceilings i ❑ ❑ 23. Cleaning Fre uenc n Structure Operation Water Well ❑ ❑ 1. Well Construction 2. Cross Connection Structure Operation Floors 3. Pro erl Graded to Sewer ❑ ❑ 4. Drain A11CA a 17 e:�. ❑ ❑ 5. Smooth/Cleanable 6. Covin S El El 7. Cleaning Frequency ' Structure Operation Walls g ❑ ❑ 8. Smooth/Cleanable ❑ ❑ 9. Cleaning Frequency 1 Structure Operation Cages ❑ ❑ 10. Condition 11. Sanitation L Structure Operation Food ❑ ❑ 12. Storage 11 El 13. Insect/Vermin Structure Operation Animal Disposal ❑ ❑ 14. Removal from Premises S� V ❑ ❑ 15. Other Structure Operation Sewage Disposal (j ❑ ❑ 16. Septic System ❑ ❑ 17. Sewer ' Structure Operation Rabies Vaccination R EIV BY INSPE ❑ ❑ 18. Certificate on Premise �Z VECTOR CONTROL INSPECTION FORM i EHD 40-06 4/6/12 Page-Of4 4