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(1) Pqu�N SAN .IOAQUIN COUNTY ' � �o. ..coG VED ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue, Stockton, CA 95205-6232 2020 N. I�� ,,�,,,,..'• Telephone: (209) 468-3420 Fax: (209) 464-0138 Web:www.sjgov.org/ehd 9 c• P Q`'FOR� EMPLOYEE HOUSING FACILITY ENVIRONMENT p RAL HEALTH ANNUAL PERMIT SELF-AUDIT HOUSING INSPECTION CHECKLISIEMIT/SER V COMPLETE ONE CHECKLIST FOR EACH HOUSING UNIT FACILITY NAME: EN, Uv- Gl( PR#: LOCATION: 2. 3 S 31 V. J MAP DESIGNATION: HOUSING UNIT INFORMATION Address or identification number of unit: Date of Inspection: o & " b j? Type of Housing Unit: ❑ Single Family Dwelling ❑ Mobile Home Other: #Employees in Unit: Date Unit First Built or In talled: l Electrical Power Provided By: PC9 Gas Provided by: HOUSING UNIT INSPECTION Interior Checklist L Comments Unit has hot and cold running water. [IN edskRe air* T Approved electrical power and gas fuel being supplied to Unit. okay ❑ Neecis Repair* ay Heater maintained in functioning and safe manner(No space/portable heaters). ❑ ee GSkRe air* Doors and windows are accessible/operable to allow for safe exiting, okay ❑ Ne ds Repair* All rooms are clean and sanitary.No insect/rodent infestations present. ❑ Okay ee s Repair* All appliances(stove,water heaters,air conditioning units,heaters)are properly vented, okay strapped and are maintained in a safe,working order, ❑ Nees Repair* All smoke and carbon monoxide detectors are present and tested to be shown in working okay order. ❑ Needs Repair* All wiring in safe,working order(no splices,exposed wires,uncovered outlets). R&Ok❑ Needs ay air* All plumbing in safe,working order(no leaks,properly maintained), [I N okay ds Repair-_ All counters,sinks,toilets,tubs,showers are working and in sanitary condition. okay ❑ veds Repair* All floors,walls,ceilings are free from holes,are not sagging or buckling,have no water X0kay leaks and are clean and in good condition. ❑ t4eas Repair* Exterior Checklist Comments Roof is properly maintained with no holes,loose shingles,leaks,etc. Elkay e s Repair* Exterior siding is maintained with no loose plaster,peeling paint,holes,etc. Elee OskRe air* r l Stairways are safe with no rotting,deteriorating,or loose parts. okay ElNeeds Re air* Wka Propane tank has barrier protection and"No Smoking"signage. El Needs Re air* The trash cans are sufficient in size,have lids and are picked up weekly. okay ❑ llee s Repair* The electrical panel is covered and protected from tampering. Ele e oskRe air* The gas fuel connection is as approved and safe. Elkay ee s Repair There are no insect or rodent infestations, okay ❑ s Repair* The sewage system is functioning,with no surfacing wastewater or backup. Okay ❑ eeds 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 information provided is true and correct to the best of my knowledge. SIGNED BY: jona 16r\ � 116,t2c) /;t4AO — ME 17 DATE TITLE EH 27-XX 4/9/2020 Employee Housing