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0 <br /> 0 <br /> V.!�' SAN .JOA ICOUNTY <br /> a '? ENVIRONMENTAL HEALTH DEPARTMENT <br /> 4 <br /> 600 East Main Street Stockton, CA 95202-3029 <br /> • �`4 R .:.:.:.�c Telephone:(209)468-3420 Fax: <br /> i (209)464-0138 Web:www.sjgov.org/ehd <br /> phW.. <br /> VECTOR CONTROL INSPECTION FORM <br /> NOREMEMEM DBA INSPECTION DATE <br /> Structureeration i r fAC� <br /> ❑ ❑ 1. Well construction PREMISE ADDRESS REINSPECTION DATE <br /> ❑ ❑ 2. Cross-Connection / /, <br /> Structure Operation Manure Management OWNER/OPERATOR PHONE G <br /> ❑ E] 3. Spreading and Disking T J 3611-®3 q <br /> ❑ ❑ 4. Concrete Tanks INSPECTION TYPE PROGRAM ELEMENT RECORD ID <br /> ❑ ❑ 5. Lagooning Y y 'i (� <br /> ❑ ❑ 6. Composting The items below represent code violations and must be corrected: <br /> Structure Operation Bird Disposal <br /> ❑ ❑ 7. Burying with 2"of Cover r'S <br /> ❑ ❑ 8. Approved Concrete Tank <br /> ❑ ❑ 9. Removal from Premises C <br /> Structure Operation Vector Control <br /> ❑ ❑ 10. Domestic FI <br /> 11. Fannia FI <br /> ❑ ❑ 12. Larvae <br /> ❑ ❑ 13. Pupae <br /> ❑ ❑ 14. Adult <br /> ❑ ❑ 15. Light Population <br /> ❑ ❑ 16. Moderate Population ` <br /> ❑ ❑ 17. Heavy Population <br /> Structure Operation Feeding/Water <br /> ❑ ❑ 18. Water Troughs <br /> ❑ ❑ 19. Cups or Bowls <br /> 20. Food Storage- <br /> Structure <br /> tora estructure Operation Houses !I'1 <br /> ❑ ❑ 21. Floors <br /> ❑ ❑ 1 22. Walls/Ceilings 1 <br /> ❑ ❑ 23. Cleaning Frequency <br /> c <br /> Structure Operation Water Well <br /> ❑ 1C-❑ 1. Well construction <br /> 2. Cross Connection <br /> Structure Operation Floors <br /> at <br /> C. ❑ 3. ProerlGraded to Sewer <br /> ❑ Lf r- ❑ 4. Drain -9 <br /> ❑ ❑ 5. Smooth/Cleanable <br /> 6. Covin <br /> 7. Cleaning Frequency <br /> Structure Operation Walls <br /> ❑ ❑ 8. Smooth/Cleanable <br /> ❑ Or ❑ 9. Cleaning Frequency <br /> Structure Operation Cages <br /> ❑ tit ❑ 10. Condition ry <br /> El if 0 11. Sanitation <br /> Structure Operation Food <br /> ❑ ❑ 12. Storage <br /> 13. Insect/Vermin IA 114L4LAd I C- <br /> Structure Operation Animal DiS OSal <br /> ❑ ❑ 14. Removal from Premises <br /> ❑ ❑ 15. Other <br /> Structure Operation Sewage Disposal <br /> ❑ ❑ 16. Septic System <br /> ❑ ❑ 17. Sewer <br /> Structure tion Rabies Vaccination RECEIV Y INSPE TOR <br /> ❑ ❑ 18. Certificate on Premises <br /> VECTOR CONTROL INSPECTION FORM <br /> EHD 40-06 12/04/08 <br /> Page of L <br />