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SAN JOAQUIN COUNTY • <br /> NMENTAL HEALTH DEPARTMENT <br /> 4: <br /> t IRo <br /> M <br /> ' 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202-2708 <br /> Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd <br /> q�/FORS <br /> VECTOR CONTROL INSPECTION FORM <br /> POULTRY RANCH DBA INSPECTONNDA <br /> Structure operation Water Well L7 <br /> ❑ ❑ 1. Well Construction PREMISE ADDRESS REINSPECTIbN DATE <br /> ❑ ❑ 2. Cross-Connection v <br /> Structure Operation Manure Management OW`N,ER/OPERATOR_/ PHONE <br /> 11 El 3. Spreading and Disking v `yv ' r QW -L <br /> ❑ ❑ 4. Concrete Tanks INSPECTION T PE PROGRAM ELEMENT R XORD ID <br /> ❑ ❑ 5. Lagooninga. 1 0 0 0 6 <br /> ❑ ❑ 6. Composting The items below represent code violations and mus be corrected: <br /> Structure Operation Bird Disposal n `` <br /> ❑ El 7. Burying with 2"of Cover ,�F-A vle 10� <br /> ❑ ❑ 8. Approved Concrete Tank <br /> ❑ ❑ 9. Removal from Premises LA 04�'' <br /> Structure Operation Vector Control <br /> ❑ ❑ 10. Domestic FI <br /> ❑ ❑ 11. Fannia Fl <br /> ❑ ❑ 12. Larvae 7Loi/1 <br /> ❑ ❑ 13. Pupae -may <br /> ❑ ❑ 14. Adult (ZBo/- - G 01 42/7 <br /> ❑ ❑ 15. Light Population <br /> ❑ ❑ 16. Moderate Population >� V► - .'t <br /> ❑ ❑ 17. Heavy Population / <br /> Structure operation Feeding/Water <br /> ❑ ❑ 18. Water Troughs <br /> ❑ ❑ 19. Cups or Bowls <br /> v15. <br /> ❑ ❑ 20. Food Storage <br /> Structure Operation Houses <br /> ❑ ❑ 21. Floors <br /> ❑ ❑ 22. Walls/Ceilings -gyp <br /> ❑ ❑ ng Frequency <br /> K E N N 9 S <br /> Structure Operation Water Well <br /> ❑ ❑ 1. Well Construction <br /> ❑ ❑ 2. Cross Connection <br /> Structure Operation Floors <br /> O+- o �- <br /> ❑ ❑ 3. Properly Graded to <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 /> Structure Operation Cages <br /> ❑ ❑ 10. Condition <br /> ❑ ❑ 11. Sanitation <br /> Structure Operation Food <br /> ❑ ❑ 12. Storage <br /> ❑ ❑ 13. Insect/Vermin <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 YR NED BY INSPE <br /> ❑ ❑ 18. Certificate on Premises <br /> EHD 40-06 6/30/2005 Page-/ Of <br />