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o�'gU1� c SAN JOAQUIN COUNTY <br /> .fix ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street Stockton, CA 95202-3029 <br /> • :.-- ;.. ;P. Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd <br /> �rFOR <br /> VECTOR CONTROL INSPECTION FORM <br /> DBA d INSPECTION DATE <br /> StructureOperation Water Well a r' <br /> ❑ ❑ 1. Well Construction PREMISE ADDRESS RE-1 SPECTION DATE <br /> ❑ ❑ 2. Cross-Connection <br /> Structure Operation Manure Mana ement OWNER/OPERATOR PHONE <br /> ❑ ❑ 13. Spreading and Disking 'S A <br /> ❑ ❑ 4. Concrete Tanks INSPECTION E PROGRAM ELEMENT RECORD ID <br /> ❑ 5. Lagooning s-I/ S <br /> ❑ ❑ 6. Composting The items below represent code violations and must be corrected: <br /> Structure Operation Bird Disposal <br /> ❑ ❑ 7. Bu in with 2"of Cover <br /> ❑ ❑ 8. Approved Concrete Tank 7 <br /> El 119. Removal from Premises ` t <br /> Structure Operation Vector Control <br /> ❑ ❑ 10. Domestic FI <br /> 11. Fannia FI <br /> ❑ ❑ 12. Larvae <br /> ❑ P- 0 <br /> 13. Pu ae <br /> 1114. Adult <br /> ❑ 15. Light Population <br /> 1:1 El16. Moderate Population <br /> ❑ 17. HeavyPopulation <br /> Structure peration Feeding/Water C <br /> ❑ ❑ 18. Water Troughs <br /> ❑ ❑ 19. Cups or Bowls <br /> ❑ 20. Food Storage <br /> Structure Operation Houses <br /> ❑ ❑ 21. Floors <br /> ❑ ❑ 22. Walls/Ceilings <br /> 11 23. Cleaning Fr uenc <br /> Structure Operation Water Well <br /> ❑ ❑ 1. Well Construction <br /> 2. Cross Connection <br /> Structure Operation Floors 0 5- <br /> 0 3. Proeri Graded to Sewer <br /> ❑ ❑ 4. Drain <br /> ❑ ❑ 5. Smooth/Cleanable <br /> 6. Covin <br /> 7. Cleaning Frequency <br /> Structure Operation Walls <br /> ❑ ❑ 8. Smooth/Cleanable <br /> ❑ ❑ 1 9. Cleaning Frequency <br /> Structure Operation Cages <br /> ❑ ❑ 10. Condition <br /> ED 11. Sanitation <br /> Structure Operation Food a <br /> ❑ ❑ 12. Storage <br /> El 13. Insect/Vermin <br /> Structure Operation Animal Dis Deal <br /> ❑ ❑ 14. Removal from Premises <br /> ❑ ❑ 15. Other <br /> Structure operation Sewage Disposal <br /> ❑ ❑ 16. Septic System <br /> ❑ ❑ 17. Sewer <br /> Structure Operetlon Rabies Vaccination RECEIVED SY INSPECTO <br /> ❑ ❑ 18. Certificate on Premises <br /> VECTOR CONTROL INSPECTION FORM <br /> EHD 40-06 12/04/08 <br /> Page_of <br />