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W1" SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street Stockton, CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd <br /> ��FOR ® ® ® p� <br /> VECTOR CONTROL INSPECTION FORM <br /> DBA INSPEC ON D TE <br /> Structure Operation Water Wei I <br /> ❑ ❑ 1. Well Construction PREMISE ADDRESSRE-INSPECTION DATE <br /> 13 [12. Cross-Connection a V(/ <br /> Structure Operation Manure Mana a nt 0R/OPERATOR PHONE <br /> 11 ❑ 3. Spreading and isking �� k 2'1V <br /> ❑ ❑ 4. Concrete Ta s INSP CTION TYPE PROGRAM ELEMENT REC RD ID <br /> ❑ El 5. Lagooning O s <br /> ❑ ❑ 6. Compos g The items below represent code violations and must be corrected: <br /> Structure Operation Bird Di osal <br /> ❑ ❑ 7. Bu n with 2"of over <br /> ❑ ❑ 8. 4roved Concrete Tank 04 <br /> ❑ ❑ 9.Aernoval from Premises J r " <br /> Structure Operation ector Control <br /> ❑ ❑ 110. Domestic FI <br /> 11. Fannia FI <br /> El ❑ 12. Larvae i <br /> ❑ 13. Pupae <br /> ❑ 14. Adult <br /> ❑ ❑ 15. Light Population <br /> ❑ ❑ 16. Moderate Population <br /> ❑ ❑ 17. Heavy Population <br /> Struc a Operation Feeding/Water <br /> ❑ 18. Water Troughs <br /> ❑ 19. Cups or Bowls <br /> 20. Food Storage <br /> structure Operation Houses <br /> ❑ ❑ 21. Floors _ <br /> ❑ ❑ 22. Walls/Ceilings <br /> ❑ ❑ 23. CleaningFrequency <br /> Structure Operation <br /> ❑ ❑ 1. Well Construction _ p� <br /> 2. Cros nnection <br /> Structure Operatio 00 <br /> ❑ ❑ 3. Proeri Graded to Sewer <br /> ❑ ❑ 4. Drain <br /> ❑ ❑ 5. Smooth/Cleanable <br /> El n 6. Covin <br /> 11 0 7. 2kSELng Fre uenc <br /> Structure Operatl <br /> ❑ ❑ 8. Smooth/Cleanable <br /> ❑ ❑ 9. Cleaning Frequency.. <br /> Structure Operatio ages <br /> ❑ ❑ 10. Condition <br /> 11. tion <br /> Stricture Operati <br /> ❑ ❑ 12. Storage <br /> 11 El <br /> 13. <br /> Structure opera Animal Disposal <br /> ❑ ❑ 14. Removal from Premises <br /> ❑ ❑ 1 15. <br /> Stricture Operation Sewage Dis o <br /> ❑ ❑ 16. Septic System <br /> Structure Opuua Rabies VBCCInatl ECEIVE INSPECTOR <br /> ❑ ❑ 18. Certificate on Premises &4A6P <br /> VECTOR CONTROL INSPECTION FORM <br /> EHD 40-06 12/04/08 <br /> Page of_ <br />