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Pte"'" • SAN JOAQUIN COUNTY 41 <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> N { 1868 East Hazelton Avenue, Stockton, California 95205-6232 <br /> . .. ;P• Telephone:(209)468-3420 Fax:(209) 464-0138 Web:www.sjgov.org/ehd <br /> Oita <br /> VECTOR CONTROL INSPECTION FORM <br /> IffiffliffilljIM DBA INSPEC ION9ATE <br /> Structure Operation �' <br /> ❑ ❑ 1. Well Construction PREMISE ADDRESS RE-INSPECTION DATE <br /> 1:1 El2. Cross-Connection // 5® - ' <br /> Structure Operation Manure Managemeryl OWNER/OPERATOR PHONE _ <br /> ❑ ❑ 3. Spreading and Dis ng <br /> E] ❑ 4. Concrete Tanks INSPECTION TYPE PROGRAM ELEMENT RECORD ID <br /> ❑ ❑ 5. Lagooning 741/4/"S <br /> ❑ ❑ 6. Composting The items below represent code violations and must be corrected: <br /> Structure Operation Bird Dispopfil <br /> ❑ ❑ 7. Bu in ith 2"of Cover <br /> ❑ ❑ 8. A ro ed Concrete Tank <br /> ❑ ❑ 9. Re val from Premises <br /> Structure Operation VeCt r control <br /> ❑ ❑ 10. omestic FI <br /> 11 Fannia FI <br /> El Els Cot <br /> . Larvae411110s <br /> ❑ ❑ 13. Pupae <br /> ❑ ❑ A 14. Adult <br /> ❑ ❑ 15. Light Population <br /> ❑ EV 16. Moderate Population <br /> ❑ 17. Heavy Population <br /> Structure 0ration Feeding/Water <br /> El ❑ 18. Water Trou hs <br /> ❑ ❑ 19. Cups or Bowls <br /> 20. Food Storage <br /> 4-ure <br /> Operation Houses <br /> ❑ 21. Floors <br /> ❑ 22. Walls/Ceilings <br /> 23. Cleanin Fre uenc <br /> Operation Water Well <br /> ❑ 1. Well Construction <br /> 2. Cross Connection <br /> M <br /> Operation Floors <br /> 3. Pro erl Graded to Sewer <br /> ❑ 4. Drain <br /> ❑ 5. Smooth/Cleanable <br /> 6. Covin R� <br /> El 0 7. Cleaning Frequency <br /> Structure Operation Walls <br /> ❑ ❑ 8. Smooth/Cleanable <br /> ❑ ❑ 9. Cleaning Frequency <br /> Structure Operation Cages ®. <br /> ❑ ❑ 10. 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 /> ❑ ❑ 16. Septic System <br /> ❑ ❑ 17. Sewer <br /> Structure Operation Rabies Vaccination RECEIVED BY INSP CTOR <br /> ❑ ❑ 18. Certificate on Premises <br /> VECTOR CONTROL INSPECTION FORM <br /> EHD 40-06 4/6/12 <br /> Page of <br />