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PQUIN SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue, Stockton, CA 95205-6232 �,rp_� Telephone: (209) 468-3420 Fax: (209) 464-0138 Web:www.sjgov.org/ehd "FORS EMPLOYEE HOUSING FACILITY ANNUAL PERMIT SELF-AUDIT HOUSING INSPECTION CHECKLIST COMPLETE ONE CHECKLIST FOR EACH HOUSING UNIT FACILITY NAME:2 PR#: LOCATION: 2 3 CIC MAP DESIGNATION: HOUSING UNIT INFORMATION Address or identification number of unit: 2 Date of Ins ection: Type of Housing Unit: ❑ Single Family Dwelling ❑ Mobile Home Other: #Employees in Unit: Date Unit First Built or In ailed: W Electrical Power Provided By: Gas Provided by: HOUSING UNIT INSPECTION Interior Checklist Comments Unit has hot and cold running water. Okay ElN s Repair*_ Approved electrical power and gas fuel being supplied to Unit. okay El 4e(;ds Repair* Heater maintained in functioning and safe manner(No space/portable heaters). Okay ❑ e s Repair* Doors and windows are accessible/operable to allow for safe exiting. Okay ❑ Npecis Repair* Akt4 { All rooms are clean and sanitary.No insect/rodent infestations present. Okay ❑ eeds Re air* All appliances(stove,water heaters,air conditioning units,heaters)are properly vented, KOkay strapped and are maintained in a safe,working order. ❑ Nee Repair* All smoke and carbon monoxide detectors are present and tested to be shown in working Okay order. ❑ Needs Repair* All wiring in safe,working order(no splices,exposed wires,uncovered outlets). okay ❑ e s Repair* All plumbing in safe,working order(no leaks,properly maintained). Okay ❑ Nee4s Repair* All counters,sinks,toilets,tubs,showers are working and in sanitary condition. Okay Elee Repair* All floors,walls,ceilings are free from holes,are not sagging or buckling,have no water XOkay leaks and are clean and in good condition. ❑ Needs Repair* Exterior Checklist j Comments Roof is properly maintained with no holes,loose shingles,leaks,etc. Okay ElNeed Repair* Exterior siding is maintained with no loose plaster,peeling paint,holes,etc. kay ❑ Needs Repair* NA Stairways are safe with no rotting,deteriorating,or loose parts. Okay ❑ Nee sRepair* Propane tank has barrier protection and"No Smoking"signage. kay ElNee Repair* The trash cans are sufficient in size,have lids and are picked up weekly. Elkay eds Repair* The electrical panel is covered and protected from tampering. Okay ❑ e Repair* The gas fuel connection is as approved and safe. Okay ❑ eeds Repair* There are no insect or rodent infestations. ❑ N kay a sRe air' The sewage system is functioning,with no surfacing wastewater or backup. Okay ❑ Needs Repair* *Needs Repair: Please specify date repairs to be completed.Any Building Permits required for repairs must be obtained and finaled. I certify that I have inspected the above noted unit and that th information provided is true and correct to the best of my knowledge. SIGNED BY: AM E IhATE TI EH 27-XX 4/9/2020 Employee Housing