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EC <br /> Z.r-,Op,- c Environme al Healt� rtment <br /> � SAN 10A � , IJ � <br /> COUNTY DEC 0 2 2019 <br /> Greatness grows here. <br /> --' Fh1V1r 0Nf,1EN'TAL HEALTH <br /> f'ERi,^I T SERViCES <br /> DAIRY FARM EMPLOYEE HOUSING <br /> ANNUAL PERMIT EXEMPTION SELF-AUDIT HOUSING INSPECTION CHECKLIST <br /> COMPLETE ONE CHECKLIST FOR EACH HOUSING UNIT <br /> FACILITY NAME: \ V PR#: <br /> LOCATION: U 0, MAP DESIGNATION: <br /> HOUSING UNIT INFORMATION <br /> Address or identification number of unit:Qw W. 4c`'- cn Date of Inspection: (, 1 <br /> Type of Housing Unit: Single Family Dwelling ❑ Mobile Home ❑ Other: <br /> #Employees in Unit: Date Unit First Built or Installed: <br /> Electrical Power Provided By: Gas Provided by: <br /> HOUSING UNIT INSPECTION _ <br /> Interior Checklist Comments <br /> Unit has hot and cold running water. Okay <br /> El Nees Repair* <br /> Approved electrical power and gas fuel being supplied to Unit. Okay <br /> ❑ Need Repair* <br /> Heater maintained in functioning and safe manner(No space/portable kay <br /> heaters). ❑ Neecis Repair* <br /> Doors and windows are accessible/operable to allow for safe exiting. okay <br /> ElNee Re air <br /> All rooms are clean and sanitary.No insect/rodent infestations present. okay <br /> El Nee Re air* <br /> All appliances(stove,water heaters,air conditioning units,heaters)are 90kay <br /> properly vented,strapped and are maintained in a safe,working order. ❑ Neeoe Repair* <br /> All smoke and carbon monoxide detectors are present and tested to be shown 90kay <br /> In working order. ❑ NeeA Repair* <br /> All wiring in safe,working order(no splices,exposed wires,uncovered outlets). fflOkay <br /> ❑ Nee Repair <br /> All plumbing in safe,working order(no leaks,properly maintained). Okay <br /> ❑ Nee Repair* <br /> All counters,sinks,toilets,tubs,showers are working and in sanitary condition. Okay <br /> ❑ Nee Re air <br /> All floors,walls,ceilings are free from holes,are not sagging or buckling,have okay <br /> no water leaks and are clean and in good condition. ❑ Needs Repair* <br /> Exterior Checklist Comments <br /> Roof is properly maintained with no holes,loose shingles,leaks,etc. ay <br /> [INe s Repair` <br /> Exterior siding is maintained with no loose plaster,peeling paint,holes,etc. EflOkay <br /> ElNeeds Repair <br /> Stairways are safe with no rotting,deteriorating,or loose parts. okay <br /> ElNeeds Repair* <br /> Propane tank has barrier protection and"No Smoking"signage. Okay <br /> ❑ Nee Repair* <br /> The trash cans are sufficient in size,have lids and are picked up weekly. Okay <br /> ❑ Nee Repair <br /> The electrical panel is covered and protected from tampering. ElNee kRe air* <br /> The gas fuel connection is as approved and safe. E] NeeOkRey air* <br /> There are no insect or rodent infestations. O y <br /> ❑ Nee Repair* <br /> The sewage system is functioning,with no surfacing wastewater or backup. Okay <br /> ❑ Needs Repair* <br /> *Needs Repair:Please specify date repairs to be com leted.Any Building Permits required for repairs must be obtained and frnaled. <br /> I certify t at I have inspeAted the above noted unit and that the information provided is true and correct to the best of my knowledge. <br /> SIGNED <br /> BY: — 6 e K-09 (. <br /> NAME - DATE TITLE <br /> F <br /> 186 'E. Hazelto Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br /> Ij <br />