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pcautN AN 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 /> �/POR p� ®gyp <br /> VECTOR® CONT INSPECTION FORM <br /> [DBAT _�j INSPECTION ATE <br /> Structure O ration m /.2Z2 <br /> ❑ ❑ 1. Well Construction PREMISE ADDRESS RE-INSPECTION DATE <br /> ❑ ❑ 2. Cross-Connection , <br /> Structure Operation Manure Mana em t OWNER/OPERATOR PHONE 2r <br /> E] 113. Spreading and Di ing <br /> ❑ E] 4. Concrete Tank INSP ION TYPE PROGRAM ELEMENT RECORD ID <br /> ❑ ❑ 5. Lagooning 44.e/ 0 1 <br /> ❑ ❑ 6. Compostin The items below represent code violations and must be corrected: <br /> Structure Operation Bird Disp sal <br /> ❑ ❑ 7. Burvi with 2"of Cover f <br /> ❑ ❑ 8. A oved Concrete Tank <br /> ❑ ❑ 9. Vmoval from Premises s`Z <br /> Structure Operation V for Control <br /> ❑ ❑ Domestic FI <br /> El 11. Fannia FI <br /> ❑ ❑ 12. Larvae -� +� z <br /> ❑ ❑ 13. Pupae <br /> ❑ ❑ 14. Adult <br /> ❑ 15. Light Population <br /> ❑ 16. Moderate Population <br /> ❑ ❑ 17. Heavy Population IV <br /> Structure Operation Feeding/Water <br /> ❑ ❑ 18. Water Troughs <br /> ❑ ❑ 19. Cups or Bowls 1 <br /> 20. Food Storage <br /> Stru ure Operation Houses <br /> ❑ 21. Floors <br /> ❑ El 22. Walls/Ceilings <br /> ❑ El23. Cleanin Fre uenc <br /> Structure Operation ate <br /> ❑ ❑ 0011. Well Construction <br /> 2. Cross Connection <br /> Structure Operati FI rs <br /> ro rl Graded to Sewer r� <br /> El El W14. Drain <br /> ❑ ❑ 5. Smooth/Cleanable <br /> 6. Covin <br /> El ­7--Gleapinq Frequency <br /> Structure Opera n Wall' �- <br /> ❑ ❑ ft& Smooth/Cleanable <br /> ❑ ❑ 9. Cleaning Frequency <br /> Structure Operation Ca <br /> ❑ ❑ 10. Condition <br /> nitation <br /> Structure Operatio Foo..2 exlee,-e, <br /> ❑ ❑ 12. Stora e <br /> El 13. Insect/Vermin <br /> Structure Operation Animal Disposal <br /> ❑ ❑ 14. Removal from Premises <br /> ❑ ❑ 15. Others <br /> Structure Operation Sewage Disposal <br /> ❑ Septic System <br /> ❑ ewer <br /> Structure Operatio Rabies Vaccination RECEIVED BY INS E T R <br /> ❑ .Certificate on Premises <br /> VECTOR CONTROL INSPECTION FORM <br /> EHD 40-06 4/6/12 <br /> Page of <br />