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Rqu1N <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> F. 1868 East Hazelton Avenue, Stockton, California 95205-6232 <br /> �q..- ,::..•;P Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd <br /> �rF ORIS p� ®p� <br /> VECTOR® CONT INSPECTION FORM <br /> DBA INSPECTION ATE <br /> Structure Operation Water Well <br /> El 1. Well Construction PREMISE ADDRESS RE-INSPECTION DATE <br /> ❑ <br /> ❑ ❑ 2. Cross-Connection 's' / r ' -A "-k <br /> Structure Operation Manure Mana eme OWNS OPERATOR P ONE <br /> ❑ ❑ 3. Spreading and Di ing 0 1- o d <br /> ❑ ❑ 4. Concrete Tanks INSP CTION TYPE PROGRAM ELEMENT RECORD ID <br /> ❑ ❑ 5. Lagooning 0 d 7 <br /> ❑ ❑ s. compostin The items below represent code violations and must be corrected: <br /> Structure Operation Bird Dispo al ,/ <br /> El El 7. Bu in ith 2°of Cover / J <br /> ❑ ❑ 8. A r ed Concrete Tank <br /> ❑ ❑ 9. R oval from Premises <br /> Structure Operation Ve or Control <br /> ❑ ❑ 11. Domestic FI <br /> 1:11. Fannia FI r <br /> El El12. Larvae <br /> ❑ ❑ 13. Pupae <br /> ❑ ❑ 14. Adult <br /> ❑ 15. Light Population _ <br /> ❑ ZI 16. Moderate Population <br /> ❑ ❑ 17. Heavy Population <br /> Structure Operation Feeding/Water <br /> El 11:1 18. Water Troughs <br /> ❑ ❑ 19. Cups or Bowls <br /> 20. Food Storage <br /> Stru ure Operation Houses <br /> C121. Floors <br /> ❑ ❑ 22. Walls/Ceilings <br /> ❑ ❑ 23. Cleaning Fre uenc <br /> StructureOperatio Wate <br /> ❑ ❑ 1. Well Construction <br /> El El 2. Cross Connection <br /> Structure OperationOrS <br /> El ❑ ropedy ropedGraded to Sewer <br /> ❑ ❑ 4. Drain <br /> ❑ ❑ 5. Smooth/Cleanable <br /> 6. Covin <br /> 7. Cl anin Frequency <br /> Structure Operation a <br /> ❑ ❑ Smooth/Cleanable <br /> ❑ ❑ <br /> Cleaning Frequency <br /> Structure Operatio <br /> ❑ ❑ A1,00. Condition <br /> Sanitation <br /> Structure Operation Food <br /> ❑ ❑ 12. Storage <br /> 13. Insect/Vermin <br /> Structure Operation Animal Disposal <br /> ❑ ❑ 14. Removal from Premises <br /> ❑ ❑ er <br /> Structure Opermi n Sewage Dispos <br /> ❑ ❑ e tic S stem <br /> ❑ ❑ <br /> Structure Operatio Rabies Vaccina . RECEIVE BY INS CTOR _ <br /> ❑ ❑ 8. Certificate on Premises <br /> VECTOR CONTROL INSPECTION FORM <br /> EHD 40-06 4/6/12 <br /> Page_of <br />