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o�QU1N SAN JOAQUIN COUNTY <br /> Ur <br /> ? ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, California 95205-6232 <br /> •aq._ _,..�P Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd <br /> �IFORta ® ® ® <br /> VECTOR CONTROL INSPECTION FORM <br /> DBA fINSPEC�TI N� ATE <br /> Structure OperationWater Well <br /> ❑ ❑ 1. Well Construction PREMISE ADDRES RE-INSPECTION DATE <br /> ❑ ❑ 2. Cross-Connection / °R <br /> Structure Operation Manure Mana etrie OWN OPERATOR PNON <br /> ❑ ❑ 3. Spreading and Dis ' g <br /> ❑ ❑ 4. Concrete Tanks IN SP TION TYPE PROGRAM ELEMENT RECORD ID <br /> ❑ ❑ 5. Lagooning <br /> ❑ ❑ 6. Composting The items below represent code violations and must be corrected: <br /> Structure Operation Bird Dispospi <br /> ❑ ❑ 7. Bu in h 2"of Cover k <br /> ❑ ❑ 8. A rov d Concrete Tank <br /> ❑ ❑ 9. Rem al from Premises <br /> Structure Operation Vect Control <br /> ❑ ❑ 10.Acmestic FI <br /> 0 El 11 Fannia FI _r _ 1 <br /> ❑ ❑ Larvae <br /> ❑ ❑ /13. Pupae <br /> ❑ ❑ 14. Adult <br /> ❑ ❑ 15. Light Population e-- 7_ <br /> El ❑ 16. Moderate Population h 'A <br /> ❑ 17. Heavy Population <br /> Structure O /W <br /> ration Feedingater <br /> El ❑ 18. Water Troughs <br /> ❑ ❑ 19. Cups or Bowls <br /> 20. Food Storage <br /> Structur Operation Houses <br /> ❑ ❑ 21. Floors <br /> ❑ 22. Walls/Ceilings <br /> ❑ "We <br /> pFrLenc <br /> Structure Operation �- V� �. <br /> ❑ ❑ onstruction <br /> s Connection <br /> Structure Operation Eyw <br /> El 1AS. Properly Graded to Sewer <br /> ❑ ❑ 4. Drain a- <br /> ❑ ❑ 5. Smooth/Cleanable <br /> 6. Covin <br /> 7. Cleaning Frequency <br /> Structure Operation <br /> ❑ ❑iperation Sooth/Cleanable <br /> ❑ g. anin Frequency <br /> Structure <br /> ❑ ondition <br /> tion <br /> Structure❑ tora e <br /> sect/Vermin <br /> structure al Dis osal <br /> ❑ moval from Premises <br /> ❑ ❑ 15. Other <br /> Structure Operation Sewage Disposal <br /> ❑ ❑ thle. Septic System <br /> ❑ ❑11 17. <br /> Structure OperatkjFj abies VaccloatfoIr RECEIVED BY INS E.9—TO <br /> ❑ ❑ F18. Certificate on Premises <br /> VECTOR CONTROL INSPECTION FORM <br /> EHD 40-06 4/6/12 <br /> Page of <br /> L <br />