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SAN JOAQUIN L'®LINTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202-2708 <br /> Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd <br /> VECTOR CONTROL INSPECTION FORM <br /> POULTRY RANCH DBA INSPECTION DATE <br /> Structure Operation Water Well Iqf <br /> 5- <br /> ❑ ❑ 1. Well Construction PREMISE ADDRESS REINSPECTION DATE <br /> ❑ 2. Cross-Con ction <br /> St- ore Operation Manure Ma agement OWNER/OPERATOR PHONE <br /> ❑ C13. Spreadi g and Disking <br /> ❑ ❑ 4. Concr e Tanks INSPECTION T E PROGRAM ELEMENT RECORD ID <br /> ❑ El5. Lag ning <br /> ❑ 6. Co posting The items below represent code violations and must be corrected: <br /> Structure eration Bird isposal <br /> ❑ X3 7. Vurying with 2"of Cover <br /> ❑ N 8.hpproved Concrete Tank <br /> ❑ 9/Removal from Premises Al- <br /> Structure Operati Lector Control <br /> ❑ ❑ 0. Domestic FI <br /> ❑ 0 V11. Fannia Fl <br /> ❑ ❑ 12. Larvae { <br /> ❑ ❑ 3. Pupae <br /> ❑ El IN. Adult <br /> ❑ ❑ 15 Li ht Population <br /> � <br /> ElI r 16. oderate Population //1 <br /> ❑ U 17. II1eavy Population <br /> Structure Op ation Feedi g/Water <br /> ❑ 10 18. W er Trough <br /> ❑ 10 19. Cu or Bowls <br /> ❑ ❑ 20. Food tors e ��p I <br /> Structure peration Houses [.� <br /> ❑ ❑ 21. Floors <br /> ❑ ❑ 22. Walls/Cei'n s <br /> ❑ E3 23. Cleaning Fr quenc <br /> KENNEL <br /> Structure Operation Water Well <br /> ❑ ❑ 1. Well Construction <br /> ❑ ❑ 2. Cross Connection <br /> Structure Operation Floors <br /> ❑ 3. Properly Graded to <br /> ❑ 0 4. Drain <br /> ❑ 0 5. Smooth/Cleanable <br /> ❑ ❑ 6. Covin <br /> El El7. Cleaning Frequency <br /> Structure Operation Walls <br /> ❑ 8. Smooth/Cleanable <br /> ❑ 9. Cleaning Frequency <br /> Structure Operation Cages <br /> ❑ ❑ 10. Condition <br /> El ❑ 11. Sanitation <br /> Structure Operation Food <br /> ❑ ❑ 12. Storage <br /> El ❑ 13. Insect/Vermin <br /> Structure Operation Animal Disposal <br /> ❑ ❑ 14. Removal from Premises <br /> ❑ ❑ 15. Other <br /> Structure Operation Sewage Disposal <br /> ❑ ❑ 16. Se tic System <br /> ❑ El 17. Sewer <br /> Structure Operation Rabies Vaccination RECEIVED INSPECTO <br /> ❑ 1 ❑ 18. Certificate on Premises <br /> OAA- <br /> EHD 40-06 6/30/2005 Page_of <br />