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PQUtN SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> Ur x <br /> 1868 East Hazelton Avenue, Stockton, California 95205-6232 <br /> a�..... :..•;P <br /> Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd <br /> VECTOR CONTROL INSPECTION FORM <br /> DBA INSPECTION DATE <br /> Structure Operation r .� /Z °7 a)� � <br /> ❑ ❑ 1. Well Construction PREMISE ADORES p RE-INSPECTION DATE <br /> ❑ ❑ 2. Cross-Connection � { C <br /> Structure Operation Manure Mana eme t OWNER/OPERATOR V PHONE <br /> ❑ ❑ 3. Spreading and Di ing "oz ( J,1 VCRS <br /> ❑ ❑ 4. Concrete Tanks/ INSP CTION PE PRQGGRR��LEMENT RECORD ID <br /> El ❑ 5. Lagooning <br /> ❑ ❑ 6. Composting The items below represent code violations and must be corrected: <br /> Structure Operation Bird Dispog6i <br /> ❑ ❑ 7. Bu in Ah 2'of Cover ° 1 <br /> ❑ ❑ 8. ApproV6d Concrete Tank <br /> ❑ ❑ 9. Re val from Premises 'd <br /> Structure Operation Vecto Control <br /> ❑ ❑ 10.Aomestic FI <br /> 1:1 El —IV Fannia FI <br /> ❑ ❑ . Larvae <br /> ❑ ❑ 13. Pupae <br /> ❑ ❑ 14. Adult <br /> ❑ ❑ 15. Light Population are <br /> ❑ EY 16. Moderate Population <br /> ❑ 17. HeavyPopulation <br /> Structure tion Feeding/Water <br /> ❑ ❑ 18. Water Trou hs <br /> ❑ ❑ 19. Cups or Bowls <br /> 20. Food Storage <br /> Struct Operation Houses <br /> ❑ 21. Floors <br /> ❑ 1 22. Walls/Ceilings <br /> ❑ ❑ 23. Cie <br /> anin Fre uen <br /> Structure Operation afar ell <br /> ❑ ❑ 1. Well Construction <br /> 2 Connection <br /> Structure Operation Flo rS <br /> Property Graded to Sewer <br /> El ElDrain <br /> 1:1 E] 5. Smooth/Cleanable <br /> 6. Covin e f <br /> 7..P!ganing Frequency <br /> Structure Operation Wa <br /> ❑ ❑ 85 Smooth/Cleanable <br /> ❑ ❑ 9. Cleaning Frequency <br /> Structure Operation Cage <br /> ❑ ❑ Condition �® <br /> 0 [71tion <br /> Structure Operatio F <br /> ❑ ❑ PJ,V12. Storage <br /> Insect/Vermin <br /> Structure Operation Animal Disposal <br /> ❑ ❑ Removal from Premises <br /> -11 <br /> ❑ ❑ 15. Other <br /> Structure Operation Sewage Disposal i <br /> ❑ ❑ 16. Septic System <br /> ❑ ❑ 17. Se <br /> Structure Operat' n Rabies Vaccinati0 RECEIVED BY 7 JINSPECTOR <br /> ❑ <br /> ElDiT.La. Certificate on Premises JV <br /> VECTOR CONTROL INSPECTION FORM <br /> EHD 40-06 4/6/12 / <br /> Page j of 4- <br />