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SAN JOAQUIN COUNTY 0 <br /> r � ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street Stockton, CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd <br /> �rFORN <br /> VECTOR CONTROL INSPECTION FORM <br /> DBA INSPECTION DATE <br /> Structure Operation ®r7 f®,3 / <br /> ❑ ❑ 1. Well Construction PREMISE ADDRESS RE-INSPECTION DATE <br /> 11 ❑ 2. Cross-Connection <br /> Structure Operation Manure Man ement OWNER/OPERATOR PHONE <br /> ❑ ❑ 3. Spreading nd Disking <br /> ❑ ❑ 4. Concrete_ <br /> oncret anks INSPECTION TYPE PROGRAM ELEMENT RECORD ID <br /> ❑ ❑ 5. Lagoo ng <br /> ❑ ❑ 6. Com sting The items below represent code violations and must be corrected: <br /> Structure Operation Bird isposal <br /> ❑ ❑ 7. in with 2"of Cover f <br /> ❑ ❑ 8/Approved Concrete Tank , <br /> ❑ ❑ Removal from Premises <br /> Structure Operation Vector Control <br /> ❑ ❑ 10. Domestic FI <br /> 11. Fannia FI <br /> ❑ ❑ 12. Larvae 17 <br /> ❑ 13. Pu ae <br /> ❑ 14. Adult <br /> ❑ 1c] <br /> 15. Light Population , <br /> ❑ 16. Moderate Po ulation <br /> 17. Heavy Population <br /> Structure Operation Feeding/Water <br /> ❑ ❑ 18. Water Troughs <br /> ❑ ❑ 19. Cups or Bowls <br /> 20. Food Storage <br /> S ture Operation Houses <br /> ❑ ❑ 21. Floors j' �.. <br /> ❑ ❑ 22. Walls/Ceilings <br /> ❑ ❑ 23. Cleanin Fr uenc <br /> monmwmmlmmmm <br /> Structure Operation Water Well <br /> ❑ ❑ 1. Well Construction ' <br /> 2. Cross Connection <br /> Structure Operation Floors <br /> ❑ 3. Properly Graded to Sewer <br /> ❑ ❑ g 4. Drain <br /> ❑ ❑ 5. Smooth/Cleanable <br /> 6. Covin <br /> El El 7. Cleaning Frequency <br /> Structure Operation Walls <br /> ❑ ❑ 8. Smooth/Cleanable <br /> ❑ ❑ 1 9. Cleaning Frequency <br /> Structure Operation I Cages <br /> ❑ ❑ rvi 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 /> ❑ ❑ 91-16. SepticSystern <br /> ❑ ❑ 17. Sewer <br /> Structure Operation Rabies Vaccination RECEIVED BY INSPE T R d <br /> ❑ ElCertificate on Premises >p f <br /> VECTOR CONTROL INSPECTION FORM <br /> EHD 40-06 12/04/08 <br /> Page of <br />