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*SAN JOAQUIN COUNTY <br /> V .yam ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street Stockton, CA 95202-3029 <br /> c� :,. :;�• Telephone:(209)468-3420 Fax:(209)464-0138 Web:wwwsjgov.org/ehd <br /> �iFOR� �® ® ®p� <br /> VECTOR CONTROL INSPECTION FORM <br /> DBA INSPECTION DATE <br /> Structure Operation w <br /> ❑ ❑ 1. Well Construction PREMISE ADDRESS KE-INSPECTION DATE <br /> ❑ ❑ 2. Cross-Connection 3 q(o <br /> Structure Operation Manure Management OWNER/OPERATOR PHONE <br /> ❑ ❑ 3. Spreading and Disking .2L16 <br /> ®.Z <br /> ❑ ❑ 4. Concrete Tanks 1 CTIO PE PROGRAM ELEMENT RECORD ID <br /> ❑ 5. Lagooning <br /> ❑ ❑ 6. Composting The items below represent code violations and must be corrected: <br /> Structure Operation Bird Disposal <br /> ❑ ❑ 7. Burying with 2"of Cover <br /> ❑ ❑ 8. Approved Concrete Tank <br /> ❑ ❑ 9. Removal from Premises 7 cl zze L <br /> Structure Operation Vector Control <br /> ❑ ❑ 10. Domestic FI <br /> 11. 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 Operation 1 Feeding/Water <br /> ❑ ❑ 18. Water Troughs <br /> ❑ ❑ 19. Cups or Bowls <br /> El 20. Food Stora e <br /> Structure Operation Houses <br /> ❑ ❑ 21. Floors <br /> ❑ ❑ 1 22. Walls/Ceilings <br /> ❑ ❑ 23. Cleaning Fr uenc <br /> Structure Operation WaterWell <br /> ❑ ❑ 1. Well Construction <br /> El 2. Cross connection <br /> Structure Operation Floors <br /> ❑ 3. PropedyGraded to Sewer <br /> ❑ ❑ 4. Drain <br /> ❑ ❑ 5. Smooth/Cleanable <br /> ❑ 0 6. Covin <br /> ❑ El 7. Cleaning Frequency <br /> Structure Operation WallS <br /> ❑ ❑ 8. Smooth/Cleanable <br /> ❑ ❑ 9. Cleaning Frequency <br /> StructureftOperaUon cages <br /> ❑ 10. Condition <br /> 11. Sanitation <br /> Stricture Food <br /> ❑ 12. Stora e <br /> El 13. Insect/Vermin <br /> Structure Animal Dis oral <br /> ❑ ❑ 1 14. Removal from Premises <br /> ❑ ❑ 1 15. Other <br /> Structure Operation Sewage Disposal <br /> ❑ ❑ 16. Septic System <br /> ❑ ❑ 17. Sewer <br /> Structure Operation Rabies Vaccination D BY % INSPECIOR <br /> ❑ ❑ 18. Certificate on Premises <br /> VECTOR CONTROL INSPECTION FORM <br /> EHD 40-06 12/04/08 <br /> Page..?,' of_ <br />