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oRQ�f" SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, California 95205-6232 <br /> •., ;P Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd <br /> qG/Fp(tt� <br /> VECTOR CONTROL INSPECTION FORM <br /> DBA ^ <br /> INSPECTION ATE <br /> Structure Operation /�/ <br /> ❑ ❑ 1. Well Construction PREMISE ADDRESS RE-INSPECTION DATE <br /> ❑ ❑ 2. Cross-Connection � / 1 <br /> Structure Operation Manure Mana eme OWNER/OPERATOR V RHONE <br /> ❑ ❑ 3. Spreading and Dis ng 7 <br /> ❑ ❑ 4. Concrete Tanks INSPECTION TYPE PROGRAM ELEMENT RECORD ID <br /> E] E] 5. Lagooning Z/*req � pi <br /> ❑ ❑ 6. Composting The items below represent code violations and must be corrected: <br /> Structure Operation Bird DispoqAl <br /> r <br /> ❑ ❑ 7. Burying ith 2°of Cover <br /> ❑ ❑ 8. ApproV6d Concrete Tank <br /> ❑ ❑ 9. Rerrl&al from Premises <br /> Structure operation VectIz <br /> r Control <br /> ❑ ❑ 10. omestic FI <br /> 1 . Fannia FI <br /> ❑ ❑ f2. Larvae 6 �2 <br /> ❑ ❑ 13. Pupae <br /> ❑ ❑ 14. Adult <br /> ❑ ❑ 15. Light Population <br /> ❑ W 16. Moderate Population <br /> El17. Heavy Population <br /> Structure O ration Feeding/Water <br /> ❑ ❑ 18. Water Troughs a� <br /> ❑ ❑ 19. Cups or Bowls <br /> 11 171 20. Food Storage <br /> Structur Operation Houses <br /> ❑ 21. Floors <br /> ❑ 22. Walls/Ceilings P <br /> ❑ 23. Cleaning Fregenu <br /> Structure Operation <br /> ❑ ❑ 1. Well Construction <br /> ss Connection <br /> Structure Operatio <br /> 11 El 3. Property Graded to Sewer <br /> ❑ ❑ 4. Drain l <br /> ❑ ❑ 5. Smooth/Cleanable <br /> 1:1 El 6. Covin <br /> 7-Sleaning Frequency <br /> Structure Operation a I <br /> ❑ ❑ 8. Smooth/Cleanable <br /> ❑ ❑ 9. Cleaning Frequency <br /> Structure Operation Cge <br /> ❑ ❑ 0. Condition <br /> El 11. Sanitation <br /> StructureOperation o <br /> El El 2. Stora e <br /> 3. Insect/Vermin <br /> Structure operation Animal Disposal <br /> ❑ ❑ . Removal from Premises <br /> ❑ ❑ 15. Other <br /> Structure Operation Sewage Disposal <br /> ❑ ❑ 16. Septic System , <br /> ❑ ❑ <br /> Structure Operation abies V - RECEIVED BY INSPECT R `.. <br /> ❑ ❑ 18. Certificate on Premises try <br /> VECTOR CONTROL INSPECTION FORM <br /> EHD 40-06 4/6/12 <br /> Page / of <br />