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SAN JOAQUIN COUNTY <br /> P�U•�N <br /> (;. <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> jio' Telephone: (209) 468-3420 Fax: (209)464-0138 Web:www.sjgov.org/ehd <br /> ORS EMPLOYEE HOUSING FACILITY <br /> ANNUAL PERMIT SELF-AUDIT HOUSING INSPECTION CHECKLIST <br /> COMPLETE ONE CHECKLIST FOR EACH HOUSING UNIT <br /> FACILITY NAME: �+ / PR#: <br /> LOCATION: Z 3 J � 5 . MAP DESIGNATION: <br /> HOUSING UNIT INFORMATION <br /> Address or identification number of unit: 2 ZII `6 Z Date of Inspection: <br /> Type of Housing Unit: ❑ Single Family Dwelling ❑ Mobile Home Other: <br /> #Employees in Unit: Date Unit First Built or In ailed: 2 <br /> Electrical Power Provided By: FIG 4 le Gas Provided by: <br /> HOUSING UNIT INSPECTION <br /> Interior Checklist Comments <br /> Unit has hot and cold running water. ❑ NOkay141 <br /> ee Repair* 61 <br /> Approved electrical power and gas fuel being supplied to Unit. kay <br /> ❑ Nees Repair* (!� <br /> Heater maintained in functioning and safe manner(No space/portable heaters). jjTOkay <br /> ❑ eds Repair* <br /> Doors and windows are accessible/operable to allow for safe exiting. Okay <br /> ❑ trqejs Re air* <br /> All rooms are clean and sanitary.No insect/rodent infestations present. Okay <br /> ❑ Needs Repair* <br /> All appliances(stove,water heaters,air conditioning units,heaters)are properly vented, XOkay <br /> strapped and are maintained in a safe,working order. ❑ Needs Repair* <br /> All smoke and carbon monoxide detectors are present and tested to be shown in working V01kay <br /> order. ❑ Aed;Repair* <br /> All wiring in safe,working order(no splices,exposed wires,uncovered outlets). kay <br /> ❑ Nvee Repair* <br /> All plumbing in safe,working order(no leaks,properly maintained). okay <br /> ❑ e d Repair* <br /> All counters,sinks,toilets,tubs,showers are working and in sanitary condition. Okay <br /> ❑ Need Repair* <br /> All floors,walls,ceilings are free from holes,are not sagging or buckling,have no water Okay <br /> leaks and are clean and in good condition. ❑ Weeas Repair* <br /> Exterior Checklist Comments <br /> ROka <br /> Roof is properly maintained with no holes,loose shingles,leaks,etc. ElNeeds Re air* <br /> Exterior siding is maintained with no loose plaster,peeling paint,holes,etc. Okay <br /> ❑ Needs Repair* AIA <br /> Stairways are safe with no rotting,deteriorating,or loose parts. kay <br /> ❑ Ne ds Repair* <br /> Op <br /> Propane tank has barrier protection and'No Smoking"signage. kay <br /> ❑ Needs Repair* <br /> The trash cans are sufficient in size,have lids and are picked up weekly. kay <br /> ❑ Need Repair* CJ <br /> The electrical panel is covered and protected from tampering. Okay <br /> ❑ Need5 Repair* <br /> The gas fuel connection is as approved and safe. kay <br /> ❑ NesReair* <br /> There are no insect or rodent infestations, ❑ N Okay <br /> ee Repair* <br /> The sewage system is functioning,with no surfacing wastewater or backup. AOkay <br /> ❑ Needs Repair* <br /> *Needs Repair: Please specify date repairs to be completed.Any Building Permits required for repairs must be obtained and finaled. <br /> I certify that I have inspected the above noted unit and t the information provided is true and correct to the best of my knowledge. <br /> SIGNED BY: Jokdm t1p /4 <br /> DAT E <br /> EH 27-XX 4/9/2020 - Employee Housing <br />