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SAN JOAQUIN COUNTY <br /> y ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street Stockton, CA 95202-3029 <br /> • q..; ;;.N;P. Telephone:(209)468-3420 Fax: (209)464-0138 Web:www.sjgov.org/ehd <br /> �/FOR <br /> p`# oar om <br /> VECTOR CONTROL INSPECTION FORM <br /> DBA /I INSPEC ION DATE <br /> Structure Operation Water Well C til r /o O <br /> ❑ ❑ 1. Well Construction PREMISE ADDRESS/ f REIN PECTI N DATE <br /> El El 2. Cross-Connection 4 6-t/ " 161 e <br /> Structure Operation Manure Mana ent OWNEOPERATOR PON <br /> ❑ ❑ 3. Spreading an Disking ���� ' I� ���/ )3&,5- Yh' <br /> ❑ ❑ 4. Concrete T ks IN PECTION TYPE / PROGRAM ELEMENT ECOf�D ID/C <br /> ❑ ❑ 5. Lagoonin ` . ��1 a�1�S/.J '3 <br /> ❑ ❑ 6. Composing The items below represent code violations and must be corrected: <br /> Structure Operation Bird Dishosal , } <br /> El E] 7. Bu with 2"of Cover /n (i' 't1Sciije /'l e <br /> ❑ ❑ 8. A roved Concrete Tank <br /> ❑ 1 ❑ 9. emoval from Premises <br /> Structure Operation V ctor Control <br /> ❑ ❑ 0. Domestic FI <br /> 11. Fannia FI 1 <br /> ❑ ❑ 12. Larvae <br /> ❑ ❑ 13. Pupae <br /> ❑ ❑ 14. Adult -. <br /> ❑ 11 15. Li ht Population , i o <br /> El 16. Moderate Population 2.d %( C� �Gt� s ` ��ve*,i?d <br /> ❑ ❑ 17. HeavyPopulation t o <br /> LCnf�tiL" k 0c ' C1LCr,S C�41Ct ii t, <br /> Structure Aeration Feeding/Water / <br /> ❑ ❑ 18. Water Troughs <br /> ❑ ❑ 19. Cups or Bowls 'fre e <br /> )/Vu i n <br /> ❑ ❑ 20. Food Storage <br /> Struc re Operation Houses S' ALL 0 O.i n cky':e <br /> ❑ 21. Floors ✓ <br /> El El22. Walls/Ceilin s Ufs (s C, Ct C`LAltd l!` a( 'e (f luSO <br /> ❑ ❑ 23. Cleaning Frequency <br /> Structure operation ate Well <br /> ❑ ❑ 1. W onstruction {� n C <br /> 2. Cross Connection <br /> Structure Operation loo <br /> ❑ ❑ . ro erlGraded to Sewer I <br /> ❑ ❑ 4. Drain <br /> ❑ ❑ 5. Smooth/Cleanable <br /> ❑ ❑ 6. Covin <br /> ❑ ❑ 7. Cleaning Frequency <br /> Structure Operation Walls <br /> ❑ ❑ 8. Smooth/Cleanable <br /> ❑ ❑ 9. Cleaning Frequency <br /> Structureeration ages <br /> ❑ ❑ 1 ition <br /> 1 ."Sanitation <br /> StructurerO <br /> O <br /> ❑ 12tors e <br /> El 13. Insect/Vermin <br /> Structure Animal Dis osal <br /> ❑ 14. Removal from Premises <br /> ❑ ❑ <br /> Structu eration ewage D posal <br /> ❑ ❑ is System <br /> ❑ ❑ 17-Sewer 1TefV0,L Fy-a - I�6 <br /> Structure 'Operation Rabies"Vaccination RECE INSPE <br /> ❑ E, ❑ 8. Certificate on Premises If <br /> VECTOR CONTROL INSPECTION FORM <br /> EHD 40-06 12/04/08 <br /> Page-/Of <br />