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PQU I,N, SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> Y 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209) 468-3420 Fax: (209)464-0138 Web:www.sjgov.org/ehd <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: C��,) l�G�� GG� 0 1 G j PR#: <br /> LOCATION: 'M /4�/t 5 r',°f-/4 L a1),�7 6 A MAP DESIGNATION: <br /> HOUSING UNIT INFORMATION <br /> Address or identification number of unit: Date of Inspection: % 11 -1 3 <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 /> ay <br /> Un,l has hot and cold running water. eels R <br /> ❑ Needs Repair <br /> Approved electrical power and gas fuel being supplied to Unit. ❑ Needs <br /> eeds Re air* <br /> Heater maintained in functioning and safe manner(No space/portable heaters). (Okay <br /> ❑ Needs Repair* <br /> Doors and windows are accessible/operable to allow for safe exiting. Okay <br /> ❑ Needs Repair* <br /> All rooms are clean and sanitary.No insect/rodent infestations present. Okay <br /> ❑ Needs Repair* <br /> All appliances(stove,water heaters,air conditioning units,heaters)are properly vented, Okay <br /> strapped and are maintained in a safe,working order. ❑ Needs Repair* <br /> All smoke and carbon monoxide detectors are present and tested to be shown in working 40kay <br /> order. ❑ N eds Repair* <br /> All wiring in safe,working order(no splices,exposed wires,uncovered outlets). ®Okay <br /> ❑ Needs Repair* <br /> All plumbing in safe,working order(no leaks,properly maintained). Okay <br /> ElNeeds Repair* <br /> All counters,sinks,toilets,tubs,showers are working and in sanitary condition. Okay <br /> [INeeds Repair* <br /> All floors,walls,ceilings are free from holes,are not sagging or buckling,have no water — kay <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. '70kay <br /> ❑ Needs Repair* <br /> Exterior siding is maintained with no loose plaster,peeling paint,holes,etc. �Dkay <br /> ❑ Needs 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 /> ❑ Needs Repair* <br /> The trash cans are sufficient in size,have lids and are picked up weekly. Okay <br /> Needs Repair* <br /> El <br /> The electrical panel is covered and protected from tampering. Okay <br /> ElNeeds Repair* <br /> The gas fuel connection is as approved and safe. <br /> Okay <br /> ❑ Needs Repair* <br /> There are no insect or rodent infestations. ❑ N Okay <br /> eds Repair* <br /> The sewage system is functioning,with no surfacing wastewater or backup. kay <br /> El 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 />