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act�,ry SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> d :< 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209)468-3420 Fax:(209)464-0138 Web:vvww.sjgov.org/ehd <br /> �4�lFORa`P <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: S 7�L � G L ? S PR#: <br /> LOCATION: L(� .� L � L MAP DESIGNATION: ..r <br /> HOUSING UNIT INFORMATION <br /> Address or identification number of unit: Date of Inspection: <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: G7 Gl <br /> HOUSING UNIT INSPECTION <br /> Interior Checklist Comments <br /> Unit has hot and cold running water. El Needs <br /> Needs Re air` <br /> E]Oay <br /> Approved electrical power and gas fuel being supplied to Unit. Needs <br /> R <br /> C1 Needs Re air` <br /> Heater maintained in functioning and safe manner(No space/portable heaters). E]Okay <br /> ❑ Needs Repair* <br /> Dc xE]s and windows are accessible/operable to allow for safe exiting. Okay <br /> eeds Repair* <br /> All rooms are clean and sanitary.No insectfrodent infestations present. Okay <br /> ❑Needs Repair* <br /> All appliances(stove,water heaters,air conditioning units,heaters)are properly vented, 90kay <br /> strapped and are maintained in a safe,working order. ❑ P eeds Repair* <br /> All smoke and carbon monoxide detectors are present and tested to be shown in working POkay <br /> order. ❑ Needs Repair* <br /> All wiring in safe,working order(no splices,exposed wires,uncovered outlets). Okay <br /> [I N eds Repair* <br /> All plumbing in safe,working order(no leaks,properly maintained). 930kay <br /> ElNeeds Repair* <br /> All counters,sinks,toilets,tubs,showers are working and in sanitary condition. rs]Okay <br /> ❑ Needs Repair* <br /> All floors,walls,ceilings are free from holes,are not sagging or buckling,have no water LE]Okay <br /> 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. .Okay <br /> ❑ Needs Repair* <br /> Exterior siding is maintained with no loose plaster,peeling paint,holes,etc. ,eeOkay <br /> ❑ Needs Repair* <br /> Stairways are safe with no rotting,deteriorating,or loose parts. ®Okay <br /> ❑Needs Repair* <br /> Propane tank has barrier protection and'No Smoking"signage. Okay <br /> [INeeds Repair <br /> The trash cans are sufficient in size,have lids and are picked up weekly. Okay <br /> ❑ Needs Repair* <br /> The electrical panel is covered and protected from tampering. ElNeeedskRey air* <br /> The gas fuel connection is as approved and safe. ®Okay <br /> [I Nees Repair* <br /> There are no insect or rodent infestations. k <br /> ❑ R Needs Re air` <br /> The sewage system is functioning,with no surfacing wastewater or backup. Okay <br /> ❑ Needs Repair* <br /> *Needs Repair: Pleasespecify date repairs to be completed.Any Building Permits required for repairs must be obtained and finaled. <br /> 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., <br /> SIGNED BY: <br /> NAME DATE TITLE <br /> EH 27-XX 9/20/2013 Dairy Farm Employee Housing <br />