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r <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, California 95205-6232 <br /> Telephone:(209) 468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd <br /> GlppFta <br /> VECTOR CONTROL INSPECTION FORM <br /> DBA _ INSPECTION ATE <br /> Structure Operation Water Well <br /> ❑ ❑ 1. Well Construction PREMISEADDRESS RE-INSPECTION DATE <br /> ❑ ❑ 2. Cross-Connection <br /> Structure Operation Manure Mana eme OWNER/OPERATOR PHONE <br /> ❑ ❑ 3. Spreading and Di ing ,369 - <br /> ❑ ❑ 4. Concrete Tanks INSPECTION TYPE PROGRAM ELEMENT RECORD ID <br /> E] ❑ 5. Lagooning $� <br /> ❑ ❑ 6. Composting/ The items below represent code violations and must be corrected: <br /> Structure Operation Bird DISpO al <br /> ❑ ❑ 7. Bu in ith 2'of Cover d <br /> ❑ ❑ 8. A r ed Concrete Tank <br /> ❑ ❑ 9. Re oval from Premises <br /> Structure Operation Vec r Control <br /> ❑ ❑ 1 Domestic FI <br /> El 'AElFannia FI <br /> ❑ ❑ 12. Larvae v <br /> ❑ ❑ Y 13. Pupae <br /> ❑ ❑ 14. Adult <br /> ❑ 15. Li ht Po ulation <br /> -'❑ i�r P�16. Moderate Po ulation e <br /> ❑ 17. Hea Population <br /> Structureperation Feeding/Water t ,fweee <br /> ❑ ❑ 18. Water Troughs <br /> ❑ ❑ 1 19. cups or Bowls <br /> 20. Food Storage <br /> o x <br /> Str tura Operation Houses '� <br /> ❑ ❑ 21. Floors <br /> ❑ ❑ 22. Walls/Ceilings <br /> ❑ ❑ 23. cleaning Frequency <br /> 7 W-WNs '1° ! 94- <br /> Structure Operation ater e <br /> ❑ Ehk . Well Construction <br /> 2. Cross Connection <br /> Structure Operatio FI S <br /> o ed Graded to Sewer <br /> ❑ ❑ . Drain <br /> ❑ ❑ 5. Smooth/Cleanable <br /> 6. Covin <br /> El El 1 7. Cleaning Frequency <br /> Structure Operation W O V®^ <br /> ❑ ❑ 8. Smooth/Cleanable <br /> ❑ ❑ 9. Cleaning Frequency <br /> Structure Operatio a e <br /> ❑ fflf3. <br /> 0. Condition <br /> itation <br /> Structure OO <br /> ❑ 2. Stora e <br /> insect/Vermin <br /> Structure Operation iS <br /> ❑ ❑ oval from Premises <br /> ❑ ❑ 15. Other <br /> Structure Operation sewage DIS <br /> ❑ ❑ Se tic System <br /> ❑ ❑ Sewer <br /> Structure Operation abies Vaccin ion RECEIVED BY INSPECTOR <br /> ❑ ❑ icate on Premises <br /> VECTOR CONTROL INSPECTION FORM <br /> EHD 40-06 4/6/12 <br /> Page of <br />