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PpUIN SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue, Stockton, CA 95205-6232 '• Telephone: (209) 468-3420 Fax: (209)464-0138 Web:www.sjgov.org/ehd �4- EMPLOYEE HOUSING FACILITY ANNUAL PERMIT SELF-AUDIT HOUSING INSPECTION CHECKLIST COMPLETE ONE CHECKLIST FOR EACH HOUSING UNIT FACILITY NAME: av, mM s PR#: LOCATION: 5 MAP DESIGNATION: HOUSING UNIT INFORMATION Address or identification number of unit: Date of Inspection: f) Type of Housing Unit: ❑ Single Family Dwelling ❑ Mobile Home Other: 11.4 #Employees in Unit: Date Unit First Built or Installed: G Electrical Power Provided By: Gas Provided by: HOUSING UNIT INSPECTION Interior Checklist Comments Unit has hot and cold running water. Okay ❑ ee Re air* Approved electrical power and gas fuel being supplied to Unit, Okay ❑ ee Repair* Heater maintained in functioning and safe manner(No space/portable heaters). okay ❑ NEjecLs Repair* Doors and windows are accessible/operable to allow for safe exiting. ❑ e okay,is air* All rooms are clean and sanitary.No insect/rodent infestations present. okay ❑ llee s Repair* All appliances(stove,water heaters,air conditioning units,heaters)are properly vented, X0kay strapped and are maintained in a safe,working order. ❑ Needs Repair* All smoke and carbon monoxide detectors are present and tested to be shown in working NOkay order. ❑ eds Repair* All wiring in safe,working order(no splices,exposed wires,uncovered outlets). okay ElNee Repair*_ All plumbing in safe,working order(no leaks,properly maintained). okay ❑ ed Repair* All counters,sinks,toilets,tubs,showers are working and in sanitary condition. Okay ❑ eds ay air* 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. ❑N16eds Repair* Exterior Checklist Comments Roof is properly maintained with no holes,loose shingles,leaks,etc. El Needs kay Repair* Exterior siding is maintained with no loose plaster,peeling paint,holes,etc. kay 1:1 NQed5 Re air* Stairways are safe with no rotting,deteriorating,or loose parts, El tfeoCsskRe air* Propane tank has barrier protection and"No Smoking"signage. EleedskRey air* >VlkaThe trash cans are sufficient in size,have lids and are picked up weekly, ❑ N eds Repair* air* The electrical panel is covered and protected from tampering. ❑ Neekay ds Repair* ROka The gas fuel connection is as approved and safe. ❑ Needs Re air* There are no insect or rodent infestations. Okay ❑ eeds Repair* The sewage system is functioning,with no surfacing wastewater or backup. Ok s ay El N ed 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 the infor ation provided is true and correct to the best of my knowledge. SIGNED BY: V �� r �) �1(414 NAM DA TITLE EH 27-XX 4/9/2020 G _ Employee Housing