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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT y < � 1868 East Hazelton Avenue, Stockton, California 95205-6232 Telephone:(209)468-3420 Fax:(209) 464-0138 Web:www.sjgov.org/ehd �4!0F 1 VECTOR CONTROL INSPECTION FORM T P DBA C INSPECTION DAT Structure Operation J ❑ ❑ 1. Well Construction PREMISE ADDRESS IRE-INSPECTION DATE ❑ ❑ 2. Cross-Connection / Structure Operation Manure Management OWNER/OPERATOR PHONE ❑ ❑ 3. Spreading and Disking � y Lry e -e5 7 ❑ ❑ 4. Concrete Tanks INSPECTION TYPE PROGRAM ELEMENT RECORD ID ❑ ❑ 5. Lagooning 2_ . ❑ ❑ 6. Composting The items below represent code violations and must be corrected: Structure Operation Bird Disposal ❑ ❑ 7. Burying with 2"of Cover a ❑ ❑ 8. Approved Concrete Tank ❑ ❑ 9. Removal from Premises PScyt)'s h144 Structure Operation Vector Control ❑ ❑ 10. Domestic FI El 11. Fannia FI ❑ ❑ 12. Larvae L ❑ ❑ 13. Pupae ❑ El 14. Adult i J ❑ ❑ 15. Light Population ❑ ❑ 16. Moderate Population ❑ ❑ 17. Heavy Population Structure Operation Feeding/Water J - ❑ ❑ 18. Water Troughs ❑ ❑ 19. Cups or Bowls U ✓ 20. Food Storage Structure Operation HOUSeS ^' ❑ ❑ 21. Floors ❑ ❑ 22. Walls/Ceilings 4 ❑ ❑ 23. Cleaning Fre 5uenc VE;N,N,E - i Structure Operation Water Well ❑ ❑ 1. Well Construction L v El 2. Cross Connection Structure Operation Floors s El ❑ 3. Pro erl Graded to Sewer ❑ ❑ 4. Drain Ad 4:1 ❑ ❑ 5. Smooth/Cleanable ❑ ❑ 6. Coving 'e ❑ ❑ 7. Cleaninq Frequency Structure Operation Walls ❑ ❑ 8. Smooth/Cleanable ❑ ❑ 9. Cleaning Frequency Structure Operation Cages ❑ ❑ 10. Condition 11. Sanitation Structure Operation Food r ❑ ❑ 12. Storage 1:1 FI 13. Insect/Vermin Structure Operation Animal Disposal ❑ ❑ 14. Removal from Premises ❑ ❑ 15. Other Q Structure Operation Sewage Disposal rJ r ❑ ❑ 16. Septic System T ❑ ❑ 17. Sewer ! BVI Structure Operation Rabies Vaccination LRECEIVE?18% / INSPECTOR ❑ ❑ 18. Certificate on Premises ` VECTOR CONTROL INSPECTION FORM f EHD 40-06 4/6/12 Page_of