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v COUNTY P°U,N SAN .1OAQUIN '� c°° ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue, Stockton, CA 95205-6232 Telephone: (209) 468-3420 Fax: (209) 464-0138 Web:www.sjgov.org/ehd F6 EMPLOYEE HOUSING FACILITY ANNUAL PERMIT SELF-AUDIT HOUSING INSPECTION CHECKLIST COMPLETE ONE CHECKLIST FOR EACH HOUSING UNIT FACILITY NAM (� E: PR#: LOCATION: 1 MAP DESIGNATION: HOUSING UNIT INFORMATION Address or identification number of unit: Date of Inspection: 6 ! Aa6 06 Type of Housing Unit: ❑ Single Family Dwelling ❑ Mobile Home ❑ Other: #Employees in Unit: Date Unit First Built or Installed: Electrical Power Provided By: V Gas Provided by: HOUSING UNIT INSPECTION Interior Checklist Comments Unit has hot and cold running water. ❑ N Okay Wl U e Repair* Approved electrical power and gas fuel being supplied to Unit. Okay f� ❑ Repair* v"C. Heater maintained in functioning and safe manner(No space/portable heaters). Okay ❑ Medjs Repair* Doors and windows are accessible/operable to allow for safe exiting. okay < ❑ NeeA Repair* All rooms are clean and sanitary.No insect/rodent infestations present. El eeds ee Repair* All appliances(stove,water heaters,air conditioning units,heaters)are properly vented, 40kay strapped and are maintained in a safe,working order. ❑ Need Repair* All smoke and carbon monoxide detectors are present and tested to be shown in working Okay order. ❑ N Repair* All wiring in safe,working order(no splices,exposed wires,uncovered outlets). elTOkay ❑ Ned Repair* All plumbing in safe,working order(no leaks,properly maintained). kay ❑ NeeD6 Re air* All counters,sinks,toilets,tubs,showers are working and in sanitary condition. El eeds eeds Repair* All floors,walls,ceilings are free from holes,are not sagging or buckling,have no water Pokay leaks and are clean and in good condition. ❑ Adds Repair* Exterior Checklist Comments Roof is properly maintained with no holes,loose shingles,leaks,etc. kay Eleds Repair* Exterior siding is maintained with no loose plaster,peeling paint,holes,etc. kay ❑ eeds Repair* Stairways are safe with no rotting,deteriorating,or loose parts. kay Elds Re air* AN Propane tank has barrier protection and"No Smoking"signage. Okay ❑ e s Repair* The trash cans are sufficient in size,have lids and are picked up weekly. Okay ❑ eeds Repair* (/A The electrical panel is covered and protected from tampering. kay El Repair* The gas fuel connection is as approved and safe. Okay ❑ eds Repair* There are no insect or rodent infestations. kay ❑ N eds Re air* The sewage system is functioning,with no surfacing wastewater or backup. Okay ❑ 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 that a information provided is true and correct to the best of my knowledge. SIGNED BY: 06 NAME DAP_ TITLE EH 27-XX 4/9/2020 - Employee Housing