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°•�4 .F`'oG SAN JOAQUIN COUNTY 4 <br /> `y ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street Stockton, CA 95202-3029 <br /> �`q,.:..:::• �P. Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd <br /> �I FORS <br /> Pt 4' CON q3G VECTOR CONTROL INSPECTION FORM <br /> DBA INSPDE <br /> Structure Operation Lavv-2 n -c-{l In <br /> ❑ ❑ 1. Well Construction PREMISE ADDRESSp J� RE-INSPECTION DATE <br /> 1:1 El 2. Cross-Connection L77 / l� , 11 i "hlt7 d c <br /> Structure Operation Manure Management OWNER/OPERATOR PHONE <br /> 1:10 1 3- Spreading an ;Disking Q aj 1tr Lin A,I't'-4?Cr q 3 <br /> ❑ ❑ 4. Concrete T ks IN PECTION TYPE PROGRAM ELEMENT RECORDID / <br /> ❑ ❑ 5. Lagoonin A11 �["� PIC L` (�'�� l(' <br /> ❑ ❑ 6. Compos ng The items below represent code violations and must be corrected: <br /> Structure Operation Bird Di Osal <br /> ❑ ❑ 7. Bu nq with 2"of over <br /> ❑ ❑ 8. A roved Concrete Tank <br /> 7- t <br /> 11 El 9. emoval from Premises �,f� it e Floor's C I S �I �../2 /'III ooe--i <br /> Structure Operation V ctor Control <br /> 11 El 10. Domestic FI /,/ <br /> L + <br /> E] ❑ 11. Fannia FI <br /> ❑ ❑ 12. Larvae <br /> ❑ ❑ 13. Pu ae �{J� 1 �1 y/�.�' <br /> El14. Adult 2-- "Q* i-c v a o l:-` 'L at n neo o r-t-/S <br /> ❑ 15. Light Population <br /> ❑ ❑ 16. Moderate Population <br /> ❑ ❑ 17. Heavy Population I� <br /> Structure Operation Feeding/Water (le �lCt C C. '1Q <br /> ❑ ❑ 18. Water Troughs <br /> ❑ ❑ 19. Cups or Bowls <br /> Ey ❑ 20. Food Storage .p /� �^ ✓� `, <br /> Stru ture Operation Houses - TUB, 1>�' 1.1f��.✓�C-LI :S trC_ <br /> ❑ 21. Floors �^ > 7 <br /> ❑ ❑ 22. Walls/Ceilings c-, ✓V1 L- / s <br /> ❑ ❑ 23. CleaningFrequency <br /> Structure operation Water Well <br /> El nstuction <br /> in y- UVr'Food 1 <br /> ❑ 1 2. Cross Connection <br /> Structure O eration <br /> ❑ ❑ "g-F7-Properly"g-F7-ProperlyGraded to Sewer <br /> ❑ ❑ 4. Drain <br /> ❑ ❑ 5. Smooth/Cleanable t <br /> 11 ❑ 6. Covin �� �"l (.(C l i A-L c oc f a-(- <br /> ❑ 7. Qjeaning Fre uenc <br /> Structure eration ally <br /> ❑ ❑ . Smooth/Cleanable s _ <br /> El 1:19. ran Frequency L� ��� �� <br /> Structure oration Ca <br /> ❑ ❑ 10. Condition <br /> 1 - Sanitation <br /> Structure Operation food <br /> ❑ ❑ ora <br /> El 0 137. n-sect/vermin <br /> Structure Operation Animal Disposal <br /> ❑ ❑ 14. Removal from Premises <br /> ❑ ❑ 15. Other <br /> Structure Oeration Sewage Disposal <br /> ❑❑ r Sep' <br /> stem <br /> 0 "I 1'�lGi 7 �11s <br /> Structure, Operation able Vaccination RE IN OR <br /> ❑ 11 18. rtiricate on Premises <br /> VECTOR CONTROL INSPECTION FORM <br /> EHD 40-06 12/04/08 <br /> Page_of <br />