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AQut" 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 /> �tFOR ® p� <br /> VECTOR CONT INSPECTION FORM <br /> DBA INSPECTION ATE <br /> Structure Operation <br /> ❑ ❑ 1. Well Construction PREMISE ADDRESS RE-INSPECTION DATE <br /> ❑ ❑ 2. Cross-Connection--/- 23 A V <br /> Structure Operation Manure Mana em!NINSPACTION <br /> OWN OPERATOR PHONE t <br /> El ❑ 3. Spreading and Di �? /31!rd � /' <br /> 1:1 E] 4. Concrete Tank TYPE PROGRAM ELEMENT RECORD ID <br /> 1:1 ❑ 5. Lagooning %-?- 10 0 f t -? <br /> ❑ ❑ 6. Composting The items below represent code violations and must be corrected: <br /> Structure Operation Bird DispO I <br /> ❑ ❑ 7. Bu in ith 2"of Cover <br /> ❑ ❑ 8. Approy6d Concrete Tank <br /> ❑ ❑ 9. Rem val from Premises <br /> Structure Operation Vect Control <br /> ❑ ❑ 10. omestic FI <br /> 11 Fannia FI <br /> ❑ ❑ Larvae -r A <br /> ❑ ❑ 13. Pupae <br /> ❑ ❑ 14. Adult e 04 <br /> ❑ ❑ 15. Light Population <br /> ❑ ❑ 16. Moderate Population <br /> ❑ 10 17. Heavy Population <br /> Structure O ration Feeding/Water ne <br /> ❑ ❑ 18. Water Troughs <br /> ❑ ❑ 19. Cups or Bowls L <br /> El L3 20. Food Stora e <br /> Structur,d Operation Houses Ite® /i � 93 -720 P <br /> ❑ 21. Floors <br /> El22. Walls/Ceilings L/ <br /> ❑ ❑ 23. Cleanin Fre uenc <br /> ME= MEEMEMI= <br /> Structure Operation Water Well ,r <br /> ❑ ❑ 1. Well Construction 1,4 <br /> 6� <br /> El F1 2. Cross Connection <br /> Structure Operation Floors <br /> 3. Properly Graded to Sewer <br /> ❑ ❑ 4. Drain <br /> ❑ ❑ 5. Smooth/Cleanable <br /> 0 El 6. Covin <br /> 1:1 El 7. Cleaning Frequency <br /> Structure Operation Wells <br /> ❑ ❑ 8. Smooth/Cleanable <br /> ❑ ❑ 9. Cleaning Frequency <br /> Structure Operation Cages <br /> ❑ ❑ 1 10. Condition <br /> El 11. Sanitation <br /> Structure Operation Food <br /> ❑ ❑ 12. Storage <br /> 13. insectivermin <br /> Structure Operation Animal Disposal <br /> ❑ ❑ 14. Removal from Premises <br /> ❑ ❑ 15. Other <br /> Structure Operation Sewage Disposal <br /> ❑ ❑ 16. Septic System <br /> ❑ ❑ 17. Sewer <br /> Structure Operation Rabies Vaccination RECEIVED BY INSPECTOR <br /> ❑ ❑ 18. Certificate on Premises <br /> VECTOR CONTROL INSPECTION FORM <br /> EHD 40-06 4/6/12 <br /> Page of <br />