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SAM JOAQUIN COUNTY' <br />m -y{ ENVIRONMENTAL HEALTH DEPARTMENT <br />::..� 600 East Main Street Stockton, CA 95202-3029 <br />�4:, ;-,:•�4 . Telephone: (209) 468-3420 Fax: (209) 464-0138 Web: www.sjgov.org/ehd <br />4FORN <br />vtG I UK GUN i KOL INSYtG I ION FOKM <br />EHD 40-06 12/04/08 <br />Page 1 of C <br />DBA <br />INSPECTION <br />DATE <br />r <br />Structure Operation <br />❑ <br />❑ <br />1. Well Construction <br />PREMISE AD ESS <br />/ S <br />REIN PECTION <br />DATE <br />❑ ❑ 2. Cross -Connection <br />Structure <br />Operation <br />Manure Management <br />OWNER/OPERATOR <br />PHONE <br />❑ ❑ 3. Spreading and Disking <br />❑ <br />❑ <br />4. Concrete Tanks <br />INP TION TYPE <br />PROGRAM ELEMENT <br />RECORD ID <br />000 s` <br />El ❑ 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 />P <br />❑ ❑ 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 />11. Fannia FI <br />❑ ❑ 12. Larvae <br />❑ <br />❑ <br />13.Pu ae <br />d <br />11 14. Adult <br />❑ <br />❑ <br />15. Light Population <br />11 El16. Moderate Population <br />1:1 <br />1:117. <br />Heavy Population <br />Structure Operation FeedingMater <br />❑ <br />❑ <br />18. Water Troughs <br />❑ ❑ 19. Cups or Bowls <br />20. Food Storage <br />Structure Operation Houses <br />❑ <br />❑ <br />21. Floors <br />❑ ❑ 22. Walls/Ceilings <br />❑ <br />Structure <br />❑1 <br />Operation <br />23. Cleanin Fr uenc <br />Water Well <br />tr <br />r <br />❑ 1. Well Constructio <br />2. Cross Connecti n <br />Struc Operation Floors <br />❑ <br />❑ <br />3. PropedyGrao6d to Sewer <br />❑ ❑ 4. Drain <br />❑ <br />❑1 <br />5. Smooth/ leanable <br />El 6. Covin <br />❑ <br />7. Cl incl Frequency <br />Structure Operati Wall <br />❑ <br />❑ N <br />8. mooth/Cleanable <br />❑ ❑ V Cleaning Frequency <br />Structure <br />Operation <br />ges <br />❑ ❑ 10. ndition <br />13 <br />11. Anitation <br />Structure Operat' n Food <br />❑ <br />12. Storage <br />El El 13. Ins ermin <br />Structure <br />olferation <br />Animal Di oral <br />❑ ❑ 14. Rernoval Premises <br />❑ <br />❑ <br />15. Other <br />If <br />Structure Operation Sewage Dispo I <br />❑ <br />❑ <br />16. Septic System <br />❑ ❑ 17. Sewer <br />Structure <br />Operation <br />Rabies vaccination <br />RECEIVED <br />x <br />INSPECTOR <br />❑ 1 ❑ 18. Certificate on Premises <br />vtG I UK GUN i KOL INSYtG I ION FOKM <br />EHD 40-06 12/04/08 <br />Page 1 of C <br />