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SAN JOAQUIN COUNTY <br /> rya 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 /> OR� <br /> VECTOR CONTROL INSPECTION FORM <br /> DBA r? ° INSP TI®DATE <br /> Structure Operation ` Y// <br /> Cl <br /> ❑ ❑ 1. Well Construction PREMISE ADDRESS RE-INSPECTION DATE <br /> ❑ ❑ 2. Cross-Connection <br /> Structure Operation Manure Mana em t OWNER/OPERATOR PHONE <br /> ❑ ❑ 1 3. Spreading and Di/king ll -Os ir a 161 <br /> ❑ ❑ 4. Concrete Tank INSP CTION TYPE PROGRAM ELEMENT RECORD ID <br /> ❑ ❑ 5. Lagooning <br /> ❑ ❑ 6. Compostin The items below represent code violations and must be corrected: <br /> structure Operation Bird Disp al <br /> ❑ ❑ 7. Burying4,ith 2"of Cover <br /> ❑ ❑ 8. ApprAed Concrete Tank <br /> ❑ ❑ 9. Re oval from Premises <br /> Structure Operation Ve or Control <br /> ❑ ❑ 1 Domestic FI <br /> . Fannia FI � <br /> ❑ ❑ 12. Larvae <br /> ❑ ❑ 13. Pupae <br /> ❑ ❑ 14. Adult <br /> ❑ ❑ 15. Light Population <br /> ❑ 16. Moderate Population <br /> ❑ 17. Heavy Population <br /> Structure O ration FeedinglWater <br /> ❑ ❑ 18. Water Troughs <br /> ❑ ❑ 19. Cups or Bowls <br /> 20. Food Storage <br /> Structure Operation Houses <br /> ❑ ❑ 21. Floors <br /> Eli ❑ 22. Walls/Ceilings oil <br /> 0 ME ❑ 23. Cleaning Fre uenc <br /> Structure Operation Water Well <br /> ❑ ❑ 1. Well Construction e <br /> 2. Cross Connection <br /> Structure Operation Floors <br /> ❑ ❑ it 3. ProerlGraded to Sewer <br /> ❑ ❑ 4. Drain 0 <br /> ❑ ❑ 5. Smooth/Cleanable <br /> 6. Covin <br /> 7. Cleaning Fre uen <br /> Structure Operation Walls <br /> ❑ ❑ 8. Smooth/Cleanable <br /> ❑ ❑ 9. Cleaning Frequency <br /> Structure operation Cages <br /> ❑ ❑ 10. Condition <br /> El 11. Sanitation <br /> Structure Operation Food <br /> ❑ ❑ 12. Storage <br /> 3. Insect/Vermin <br /> Structure Operation Animal Dis oral <br /> ❑ ❑ 14. Removal from Premises <br /> ❑ ❑ 5. Other <br /> Structure Operation Sewage Disposal <br /> ❑ ❑ 16. Septic System <br /> ❑ ❑ Sewer <br /> Structure Operbtion Rabies Vaccination REC VED IN P CT R <br /> ❑ 1 ❑ 1 18. Certificate on Premises <br /> VECTOR CONTROL INSPECTION FORM <br /> EHD 40-06 12/04/08 <br /> Page / of <br />