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PO U i N SAN JOAQUIN COUNTY* <br />)O �t COG <br />` ENVIRONMENTAL HEALTH DEPARTMENT <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202-2708 <br />Telephone: (209) 468-3420 Fax: (209) 464-0138 Web: www.sjgov.org/ehd <br />i'g60 <br />VECTOR CONTROL INSPECTION FORM <br />EHD 40-06 6/30/2005 4 'JJ -/j <br />Page _ of _ <br />POULTRY RANCH <br />DBA <br />C k <br />INSPECTION DATE <br />r -- <br />Structure Operation Water Well <br />❑ <br />❑ <br />1. Well Construction <br />PREMISE AtIBRESS <br />REINSPECTION DATE <br />❑ ❑ 2. Cross-Connection11 <br />Structure <br />Operation <br />Manure Management <br />OWNER/OPERATOR <br />Al } <br />PHONE <br />3 <br />o i _ "7 .34'93 <br />❑ ❑ 3. Spreading and Disking <br />❑ <br />1 ❑ <br />4. Concrete Tanks <br />INSPECTION TYPE <br />AD,� <br />PROGRAM ELEMENT <br />41q s- <br />RECORD ID <br />M 0 e"`>`I <br />❑ ❑ 5. Lagooning <br />❑ <br />❑ <br />6. Composting <br />The items below represent code violations and must be corrected: <br />Structure <br />Operation <br />Bird Disposal <br />/ <br />/ <br />E]❑ 7. Burying with 2" of Cover{ <br />❑ <br />❑ <br />8. Approved Concrete Tank <br />❑ ❑ 9. Removal from Premises <br />Structure <br />Operation <br />Vector Control <br />❑ ❑ 10. Domestic FI <br />❑ <br />❑ <br />11. Fannia FI <br />» <br />r/ <br />Z,,i <br />❑ ❑ 12. Larvae <br />❑1 <br />❑ <br />13. Pupae <br />N ,J�A CA <br />❑ ❑ 14. Adult <br />❑ <br />❑ <br />15. Light Population <br />V'C,,, <br />❑ ❑ 1 16. Moderate Population <br />❑ <br />❑ <br />17. Heavy Population <br />l <br />[ , <br />Structure Operation Feeding/Water <br />❑ <br />❑ <br />18. Water Troughs <br />V <br />❑ ❑ 19. Cups or Bowls <br />❑ <br />❑ <br />20. Food Storage <br />i. C) ' <br />Structure Operation Houses <br />❑ <br />❑ <br />21. Floors <br />ca"A 14k <br />j4 <br />❑ ❑ 22. Walls/Ceilings <br />❑ <br />❑ <br />23. Cleaning Frequency <br />G -at k� <br />„Ycyl <br />;"�a 1✓t� i c' <br />CA, r C) <br />} <br />KENNEL <br />Structure Operation Water Well <br />❑ ❑ 1. Well Construction <br />❑ <br />❑ <br />2. Cross Connection <br />\"\/� f <br />\ <br />!L- <br />Structure Operation Floors <br />❑ <br />❑ <br />3. Properly Graded to <br />❑ ❑ 1 4. Drain <br />❑ <br />❑ <br />5. Smooth/Cleanable <br />❑ ❑ 6. Covin <br />❑ <br />❑ <br />7. Cleaning Fre uenc <br />_ <br />A <br />m v3 <br />'Ar <br />Structure Operation Walls <br />❑ <br />❑ <br />8. Smooth/Cleanable <br />/ <br />❑ ❑ 1 9. Cleaning Frequency <br />Structure <br />Operation <br />Cages <br />' '� 1 ✓� <br />, <br />- (j <br />❑ ❑ 10. Condition <br />❑ <br />❑ <br />11. Sanitation <br />4 <br />Structure Operation Food <br />❑ <br />❑ <br />1 12. Storage <br />❑ ❑ 13. Insect/Vermin <br />Structure <br />Operation <br />Animal Disposal <br />❑ ❑ 14. Removal from Premises <br />❑ <br />❑ <br />15. Other <br />Structure Operation Sewage Disposal <br />❑ <br />❑ <br />16. Septic System <br />❑ ❑ 17. Sewer <br />Structure <br />Operation <br />Rabies Vaccination <br />RECEIVED BY <br />.� <br />=INSPCOR <br />❑ ❑ 18. Certificate on Premises <br />EHD 40-06 6/30/2005 4 'JJ -/j <br />Page _ of _ <br />