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oP`it'!!y c SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street Stockton, CA 95202-3029 <br /> • c��:• ;•:•;� • Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd <br /> VECTOR CONTROL INSPECTION FORM <br /> DBA a r INS ION A E <br /> %structure Operation Water Well VIQA <br /> Nt❑ ❑ 1. Well Construction PREMISE ADDRESS RE-INSPEC ION DATE <br /> ❑ 2. Cross-Connection <br /> S ure operation Manure Managegfient OWNE OPERATOR PMOINE <br /> ❑ ❑ 3. Spreading and Asking UC <br /> ❑ ❑ 1 4. Concrete TanINS ECTi N TY P GRAM ELEMENT CORD ID <br /> ❑ 5. Lagooning S <br /> 0149, <br /> C3 ❑ 6. Compostirill The items below represent code violations and must be corrected: <br /> Structure Operation Bird Disp sal <br /> ❑ ❑ 7. Bu in with 2"of Cover <br /> ❑ ❑ 8. Apojved Concrete Tanke r <br /> 119. R oval from Premises Cr ` co <br /> Structure Ope tion Ve or Control <br /> ❑ 1 Domestic FI <br /> El 1. Fannia FI <br /> ❑ ❑ 12. Larvae f 8 <br /> 41r\ AM(,& <br /> ❑ ❑ 13. Pupae <br /> ❑ ❑ . Adult <br /> ❑ EY 1 Light Population i <br /> ❑ 16. oderate Population 1 ® Cd. �/ , Qr <br /> 1317. H Population <br /> Structure peration Feeds Mater <br /> ❑ ❑ 18. Water rou hs ® \ n ® t <br /> El 11C 19. Cups or owls ' 1 <br /> In <br /> 20. Food Stor e <br /> Operation Houses <br /> ❑ 1 21. Floors 17r <br /> ❑ 22. Walls/Ceilings rElh JAC, ak ORSAle- <br /> ❑ 23. Cleaning Fre uenc <br /> Structure Operation Water Well <br /> ❑ ❑ 1 1. Well Construction X V S <br /> 2. Cross Connection >< <br /> Structure Operation Floors <br /> E3 3. Proed Graded to Sewer <br /> ❑ ❑ 4. Drain <br /> ❑ ❑ 5. Smooth/Cleanable X <br /> 0 El 6. Covin 0( <br /> 7. Cleaning Frequency X <br /> Structure Operation Walls <br /> ❑ ❑ 8. Smooth/Cleanable K <br /> ❑ ❑ 9. Cleaning Frequency K <br /> Structure Operation Cages <br /> ❑ ❑ 10. Condition X <br /> 11. Sanitation k <br /> Structure Operation Food <br /> ❑ ❑ 12. Storage A <br /> 13. Insect/Vermin X <br /> Structure Operation Animal Disposal <br /> ❑ ❑ 14. Removal from Premises <br /> ❑ 1❑ 15. Other A (r 1 l j <br /> Structure_ Operation Sewage Disposal b { ® "4 <br /> ❑ ❑ 16. Septic System A i <br /> ❑ ❑ 17. Sewer X q t`1� ESCO <br /> IL <br /> Structure Operation Rabies Vaccination REC ED BY IN,SP9CTOR RA <br /> ❑ ❑ 18. Certificate on Premises <br /> VECTOR CONTROL INSPECTION FORM <br /> EHD 40-06 12/04/08 <br /> Page_of_ <br />