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SFipp pp ' ®UN 1 i®w TY <br /> 0.uiN N � M <br /> `X ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, California 95205-6232 <br /> • q.. :..•;P• Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd <br /> �rFOitl1 <br /> VECTOR CONTROL INSPECTION FORM <br /> DBA <br /> INSPECTIOtl DAT w <br /> Structure Operation Water Well ! l`� <br /> ❑ ❑ 1. Well ConstructionPREMISE ADDRESS RE-INSPECTION DATE <br /> ❑ ❑ 2. Cross-Connection <br /> 4 '2 Y'3'0-0 W 07Y a-.Z-e_ 41, 6 <br /> Structure Operation Manure Mana eme t OWNER/OPERATOR V <br /> /PHONE <br /> ❑ ❑ 3. Spreading and Di ing 13 <br /> C 1 <br /> ❑ ❑ 4. Concrete Tanks INSP CT&TYPEPROGRAM ELEMENT RECORD ID <br /> El F15. Lagooning7' q <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 <br /> ❑ ❑ 8. Appro ed Concrete Tank <br /> ❑ ❑ 9. Re vat from Premises <br /> Structure Operation vect r Control V. <br /> ❑ ❑ 10.12.metic FI <br /> 1:1 F1 14. Fannia FI J <br /> ❑ ❑ 2. Larvae ys <br /> ❑ ❑ 13. Pupae <br /> ❑ ❑ 14. Adult <br /> ❑ ❑ 15. Li ht Population - <br /> � .'Yt <br /> ❑ 16. Moderate Population <br /> ❑ 17. eavy Population <br /> Structureration FeedingMater <br /> ❑ ❑ 18. Water Trou hs <br /> ❑ ❑ 19. Cups or Bowls <br /> 20. Food Storage <br /> Structu Operation Houses <br /> ❑ 21. Floors <br /> ❑ 22. Walls/Ceilings <br /> ❑ ❑ 23. aeanin Fre uenc <br /> Structure Operation r <br /> ❑ ❑ A J11. Well Construction <br /> 2. Cross Connection <br /> Structure Operati FIOor <br /> -_37-15-roperly Graded to Sewer <br /> ❑ ❑ . Drain <br /> ❑ ❑ 5. Smooth/Cleanable <br /> 6. Covin ®� <br /> El El leanin Frequency <br /> Structure Operati W0 ./ <br /> ❑ ❑ . Smooth/Cleanable <br /> ❑ ❑ . Cleanina Frequency <br /> Structure Operation a <br /> ❑ ❑ 10. Condition <br /> El tion <br /> Structure Operati FOO <br /> ❑ ❑ 12. Stora e <br /> 13. Insect/Vermin <br /> Structure Operation Animal Disposal <br /> ❑ ❑ 14. Removal from Premises <br /> ❑ ❑ 15 <br /> Structure operatio< Sewage Rooed <br /> ❑ ❑ <br /> Septic System <br /> ❑ ❑ _ Sewer <br /> Structure Operation Rabies Vaccination REC D BY IN T R <br /> ❑ ❑ 18. Certificate on Premises <br /> VECTOR CONTROL INSPECTION FORM <br /> EHD 40-06 4/6/12 <br /> Page of <br /> I <br />