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PQ 11" SAN JOAQUIN COUNTY <br /> 2` ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 East Weber Avenue, 3`d Floor, Stockton, CA 95202-2708 <br /> Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd <br /> VECTOR CONTROL INSPECTION FORM <br /> POULTRY RANCH DBA INSPECTIOND TE <br /> a <br /> Structure Operation Water Well ,t(� / <br /> 11 1. Well Construction PREMISE ADDRESS REIN T DATE <br /> ❑ ❑ 2. Cross-Connection l� ®r <br /> 19 <br /> Structure Operation Manure Management OWNER/OPERATOR rMUNIZ <br /> ❑ ❑ 3. Spreading and Disking {ev^va c+ACP --- <br /> ❑ ❑ 4. Concrete Tanks INSPECTION TYPE PROGRAM ELEMENT RECORD ID <br /> ❑ ❑ 5. Lagooning -k rin <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 p <br /> ❑ 119. Removal from Premises ���� } ne2o / � <br /> Structure Operation Vector Control <br /> ❑ El 10. Domestic Fl <br /> 11. Fannia Fl j <br /> ❑ ❑ 1 12. Larvae ` ` <br /> ❑ ❑ 1 13. Pupae <br /> ❑ 14. Adult <br /> ❑ ❑ 15. Light Population <br /> ❑ ❑ 16. Moderate Population tO° <br /> ❑ El 17. Heavy Population <br /> Structure Operation Feeding/Water ` <br /> ❑ ❑ 18. Water Troughs <br /> ❑ El 19. Cups or Bowls <br /> ❑ El 20. Food storage fN <br /> p i <br /> Structure Operation Houses H ! d <br /> ❑ ❑ 21. Floors <br /> ❑ ❑ 22. Walls/Ceilings <br /> ❑ ❑ 23. Cleaning Frequency <br /> KENNEL <br /> Structure311 <br /> J2. <br /> Water Well P A s <br /> . Well Construction <br /> EN Cross ConnectionStructureloors <br /> . Properly GTj6d to <br /> ^ r <br /> ❑ 4. Drain01 <br /> 5. Smoo Cleanable <br /> ❑ ❑ 6. Cq#mg { <br /> ❑ 7. leaning Frequency <br /> Structure Operation alts <br /> ❑ ❑ . Smooth/Cleanable <br /> ❑ 9\Cleaning Fre uenc 1 d <br /> Structure Opera n Cakes �7 <br /> ❑ 10. kondition �1' 1)1 f <br /> ❑ ❑ H. Sa nation <br /> Structure Operation Food 4-0 <br /> ❑ ❑ 12. Storale <br /> ❑ 13. msec ermin <br /> strn re Operation Animal Dis sal r <br /> ❑ 14. Removal om Premises <br /> ❑ 15. Other y <br /> s ructure Operation Sewage Disposa <br /> �- AMC') <br /> ❑ ❑ 16. Se tic S Ste <br /> ❑ ❑ 17. Sewer <br /> Structure Operation Rabies Vaccination RECEIVED BY INSPECT <br /> ❑ ❑ 18. Certificate on Premises <br /> EHD 40-06 6/30/2005 / Page of 4- <br />