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oPQURf" SAN JOAQUIN COUNTY <br />at .� ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 East Hazelton Avenue, Stockton, California 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 464-0138 Web: www.sjgov.org/ehd <br />�/FOR <br />VECTOR CONTROL INSPECTION FORM <br />OEM DBA INSPECT ON ATE <br />Structure Operation Ys 0 1 ®� <br />❑ ❑ 1. Well Construction PREMISE ADDRESS RE -INSPECTION DATE <br />❑ ❑ 2. Cross -Connection <br />Structure Operation Manure manage t OWNER/OPERATOR P ONE <br />1:1 E]3. Spreading and Di ing . ✓ ."r� C� 6� `i� f - 3 VO. - <br />E] ❑ 4. Concrete Tank a INSP CTION TYPE PROGRAM ELEMENT REC RD ID <br />11 E]5. Lagooning 4*'� AZO ae <br />❑ ❑ 6. Composting The items below represent code violations and must be corrected: <br />Structure Operation Bird Dispogfil <br />❑ ❑ 7. Bu in ith 2° of Cover <br />❑ 1 ❑ 8. Apprv6d Concrete Tank o <br />❑ ❑ 9. Re val from Premises <br />Structure Operation vect r control <br />❑ ❑ 10. omestic FI <br />_13K Fannia FI / <br />❑ ❑ h. Larvae <br />❑ ❑13. Pupae <br />El El14. Adult <br />❑ ❑ 15. Light Population -� <br />❑ 16. Moderate Population <br />❑ 17. Heavy Population <br />Structure O ration FeedingMater <br />❑ ❑ 18. Water Troughs <br />❑ ❑ 19. Cups or Bowls e <br />20. Food Storage <br />StructuV Operation Houses <br />❑ 21. Floors 12-? 'e�- <br />❑ 22. Walls/Ceilings <br />❑ ❑ 23. Cleaning Fre uenc <br />Structure Operation Wate! <br />❑ ❑ ell Construction <br />ss Connection <br />Structure Operati F12CM <br />Properly Graded to Sewer <br />❑ ❑ Drain <br />❑ ❑ 5. Smooth/Cleanable <br />El 6. Covin <br />7ning Frequency <br />Structure Operation W S <br />❑ ❑ . Smooth/Cleanable <br />❑ ❑ 9Qg= Frequency <br />Structure Operation C <br />❑ ❑ ht10. Condition <br />El El anitation <br />Structure Operatio FOO <br />❑ ❑ Storage <br />13. Insect/vermin <br />Structure Operation Animal Disposal <br />❑ ❑ 14. Removal from Premises <br />❑ ❑ 15. Other <br />Structure Operation Sewage Disposal <br />❑ . Septic System <br />❑ ❑ 17. S <br />Structure Operati RableS -RECEIV BY INSPECTOR <br />0 <br />E:] ❑ Certificate on Premises ✓ r' <br />VECTOR CONTROL INSPECTION FORM <br />EHD 40-06 4/6/12 Page of <br />