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P°U•IN SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue, Stockton, CA 95205-6232 �j�` ,�'• Telephone: (209) 468-3420 Fax: (209) 464-0138 Web:vvvvw.sjgov.org/ehd • c. P Fi-6 EMPLOYEE HOUSING FACILITY ANNUAL PERMIT SELF-AUDIT HOUSING INSPECTION CHECKLIST COMPLETE ONE CHECKLIST FOR EACH HOUSING UNIT FACILITY NAME: 1 SAD 4tj PR#: LOCATION: �. �AG O MAP DESIGNATION: HOUSING UNIT INFORMATION. Address or identification number of unit: 2 Date of Inspection: Type of Housing Unit: ❑ Single Family Dwelling ❑ Mobile Home Xother #Employees in Unit: Date Unit First Built or Instilled: 16 Electrical Power Provided By: Gas Provided by: 77 HOUSING UNIT INSPECTION Interior Checklist Comments Okay /�/ Unit has hot and cold running water. ❑ ee Repair* (yJ Okay Approved electrical power and gas fuel being supplied to Unit. ❑ e s Re air* Pp Oka / Heater maintained in functioning and safe manner(No space/portable heaters). Eleed Rye air* Doors and windows are accessible/operable to allow for safe exiting. kay ❑VsRe AJ All rooms are clean and sanitary.No insect/rodent infestations present. ❑All appliances(stove,water heaters,air conditioning units,heaters)are properly vented,stra ed and are maintained in a safe,workin order. ❑ All smoke and carbon monoxide detectors are present and tested to be shown in working Okay order. ❑ eeds Repair* VRe All wiring in safe,working order(no splices,exposed wires,uncovered outlets). ❑All plumbing in safe,working order(no leaks,properly maintained). ❑All counters,sinks,toilets,tubs,showers are working and in sanitary condition. ❑ All floors,walls,ceilings are free from holes,are not sagging or buckling,have no water Okay leaks and are clean and in good condition. ❑ eeds Repair* Exterior Checklist Comments kay 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. ❑ Re air* Okay Propane tank has barrier protection and"No Smoking"signage. ❑ eed Re air* The trash cans are sufficient in size,have lids and are picked up weekly. ❑ ee kay ay air* Okay The electrical panel is covered and protected from tampering. Tee air* The gas fuel connection is as approved and safe. air* There are no insect or rodent infestations. air* The sewage system is functioning,with no surfacing wastewater or backup. air* *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: &10a� NAME DAT TITL Employee Housing EH 27-XX 4/9/2020 _. ... .