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SAN JOAQUIN COUNTY <br /> Irl ? ENVIRONMENTAL HEALTH DEPARTMENT <br /> X <br /> 1868 East Hazelton Avenue, Stockton, California 95205-6232 <br /> Q., w ..;P• Telephone:(209)468-3420 Fax: <br /> i (209)464-0138 Web:www.sjgov.org/ehd <br /> �r o..., <br /> VECTOR CONTROL INSPECTION FORM <br /> DBAINSPECTION DATE <br /> Structure Operation Water Well <br /> ❑ ❑ 1. Well Construction PREMISE ADDRESS RE-INSPECTION DATE <br /> ❑ ❑ 2. Cross-Connection 7.S-1 y7 <br /> Structure Operation Manure Mana eme t O17", <br /> OPERATOR P ONE <br /> ❑ ❑ 3. Spreading and Di ing t® -1) -? - 0 <br /> ❑ ❑ 4. Concrete Tank (NSP CTION TYPEPROGRAM ELEMENT RECORD ID <br /> 11 E] 5. Lagooning <br /> ❑ ❑ 6. Compostin The items below represent code violations and must be corrected: <br /> Structure Operation Bird Dlsp al <br /> ❑ ❑ 7. Bu in with 2°of Cover A ' <br /> ❑ ❑ 8. A r ed Concrete Tank <br /> ❑ ❑ 9. Re oval from Premises aca, <br /> Structure Operation VeFPr Control 01 <br /> ❑ ❑Lj /Domestic FI <br /> 1 . Fannia FI <br /> ❑ ❑ 12. Larvae <br /> ❑ ❑ 13. Pupae <br /> ❑ ❑ 14. Adult <br /> ❑ 15. Light Population <br /> ❑ 16. Moderate Population 74, r -f ' /, _ e4,,.,0 G.0 <br /> 22 94o <br /> ❑ ❑ 17. Heavy Population <br /> Structure Operation Feeding/Water <br /> ❑ ❑ 18. Water Troughs <br /> ❑ ❑ 19. Cups or Bowls <br /> 20. Food Storage <br /> �E] <br /> u ure Operation Houses / <br /> El 21. Floors <br /> ❑ 22. Walls/Ceilings <br /> ❑ ❑ 23. Cleaning FrequencyA <br /> Structure Operation Water Well <br /> ❑ ❑ 1. Well Construction <br /> El 2. Cross Connection <br /> Structure Operation Floors I- ecer ,- o 37 <br /> 3. Properly Graded to Sewer <br /> ❑ ❑ 4. Drain <br /> ❑ ❑ 5. Smooth/Cleanable _ <br /> 6. Covin <br /> 7. Cleaning Frequency <br /> Structure Operation WaIIS <br /> ❑ ❑ Smooth/Cleanabie <br /> El 119. CleaningFrequency ® <br /> Structure Operation Cages <br /> ❑ ❑ 110. Condition <br /> 11. Sanitation <br /> Structure Operation Food <br /> ❑ ❑ 12. Storage <br /> 13. insect/vermin <br /> Structure Operation Animal Disposal <br /> ❑ ❑ 14. Removal from Premises <br /> ❑ ❑ 15. Other <br /> Structure Operation Sewage Disposal <br /> ❑ ❑n y 16. Septic System <br /> ❑ ❑ 17. Sewer <br /> Structure Operation 4ables Vaccination RECEIVE Y INS TOR <br /> ❑ ❑ Certificate on Premises <br /> VECTOR CONTROL INSPECTION FORM <br /> EHD 40-06 4/6/12 <br /> Page_of <br />