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5 PpUIN SAN .JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT .< 1868 East Hazelton Avenue, Stockton, CA 95205-6232 N. _ .� • ' Telephone: (209) 468-3420 Fax: (209) 464-0138 Web:wvvw.sjgov.org/ehd Q�,FOR� EMPLOYEE HOUSING FACILITY ANNUAL PERMIT SELF-AUDIT HOUSING INSPECTION CHECKLIST COMPLETE ONE CHECKLIST FOR EACH HOUSING UNIT FACILITY NAME: 4 PR#: LOCATION: S S. MAP DESIGNATION: HOUSING UNIT INFORMATION Address or identification number of unit: Date of Inspection: 0 f Type of Housing Unit: ❑ Single Family Dwelling ❑ Mobile Home Other: #Employees in Unit: Date Unit First Built or Ins Iled: Electrical Power Provided By: P Gas Provided by: HOUSING UNIT INSPECTION Interior Checklist Comments Okay Unit has hot and cold running water. ❑ eeds Repair kay Approved electrical power and gas fuel being supplied to Unit. ❑ qeeas Re air* kay Heater maintained in functioning and safe manner(No space/portable heaters). ❑7N , Repair* Okay Doors and windows are accessible/operable to allow for safe exiting, ❑ eeds Repair* kay All rooms are clean and sanitary.No insect/rodent infestations present. leds s Re air* All appliances(stove,water heaters,air conditioning units,heaters)are properly vented, Okay strapped and are maintained in a safe,workingorder. Repair* All smoke and carbon monoxide detectors are present and tested to be shown in working kay order. ❑ N eds Repair* Okay All wiring in safe,working order(no splices,exposed wires,uncovered outlets). ❑ Nee Repair* Okay All plumbing in safe,working order(no leaks,properly maintained). ❑ tTleed Repair* kay All counters,sinks,toilets,tubs,showers are working and in sanitary condition. ❑ �Repair* * All floors,walls,ceilings are free from holes,are not sagging or buckling,have no water leaks and are clean and in good condition. ❑ Exterior Checklist Comments Okay Roof is properly maintained with no holes,loose shingles,leaks,etc. ❑ Needs Re air* Okay Exterior siding is maintained with no loose plaster,peeling paint,holes,etc. ❑ eds Re air* Okay Stairways are safe with no rotting,deteriorating,or loose parts. ❑ ds Repair* kay Propane tank has barrier protection and"No Smoking"signage. ❑ Ne ds Repair* kay The trash cans are sufficient in size,have lids and are picked up weekly. O N ed Re airy Okay The electrical panel is covered and protected from tampering. ❑ N d Re air* Okay The gas fuel connection is as approved and safe. ❑ Ne Repair* Okay There are no insect or rodent infestations. ❑ N Repair* Okay The sewage system is functioning,with no surfacing wastewater or backup. ❑ e ds 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 thcAthe inform tion provided is true and correct to the best of my knowledge. SIGNED BY: (01 4 �� 'ri- NAME D TE E Employee Housing EH 27-XX 4/9/2020 ..._. ... .