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a� SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> L 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> a Telephone: (209) 468-3420 Fax: (209)464-0138 Web:www.sjgov.org/ehd <br /> c c <br /> 4C/FORS` DAIRY FARM EMPLOYEE HOUSING <br /> ANNUAL PERMIT EXEMPTION SELF-AUDIT HOUSING INSPECTION CHECKLIST <br /> / COMPLETE ONE CHECKLI,SST/FOR EACH HOUSING UNIT <br /> FACILITY NAME: ' `) I' L"_/ �L L l✓` �/�U PR#: I, <br /> LOCATION: L_(/ ,, �/� 4471r )rxdX✓C'� MAP DESIGNATION: <br /> HOUSING UNIT INFORMATION <br /> Address or identification number of unit: Date of Inspection: j 7� 3 <br /> Type of Housing Unit: ❑ Single Family Dwelling Mobile Home ❑ Other: <br /> #Employees in Unit: K;' Date Unit First Built or Installed: <br /> Electrical Power Provided By: Gas Provided by: J C <br /> HOUSING UNIT INSPECTION <br /> Interior Checklist Comments <br /> ay <br /> Unit has hot and cold running water. R <br /> ❑ N beds eds Repair <br /> Ap)roved electrical power and gas fuel being supplied to Unit. Okay <br /> ❑ Needs Repair* <br /> Heater maintained in functioning and safe manner(No space/portable heaters). Okay <br /> E] Needs Repair* <br /> Doors and windows are accessible/operable to allow for safe exiting. Okay <br /> ❑ Needs Repair* <br /> ay <br /> All rooms are clean and sanitary.No insect/rodent infestations present. eeds R <br /> E3eds Re air* <br /> All appliances(stove,water heaters,air conditioning units,heaters)are properly vented, 00kay <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 (Okay <br /> order. ❑ Needs Repair* <br /> All wiring in safe,working order(no splices,exposed wires,uncovered outlets). Okay <br /> ❑ Needs Re air* <br /> All plumbing in safe,working order(no leaks,properly maintained). ]Okay <br /> ❑ Needs Repair* <br /> All counters,sinks,toilets,tubs,showers are working and in sanitary condition. kay <br /> ❑ Needs Repair* <br /> All floors,walls,ceilings are free from holes,are not sagging or buckling,have no water ffOkay <br /> lea;s 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 /> [INeeds Repair* <br /> Exterior siding is maintained with no loose plaster,peeling paint,holes,etc. Okay <br /> ❑ Needs Repair* <br /> ay <br /> Stairways are safe with no rotting,deteriorating,or loose parts. El <br /> R <br /> El Needs 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 /> ❑ N eds Repair* <br /> The electrical panel is covered and protected from tampering. El N kay <br /> eds Repair* <br /> ay <br /> The gas fuel connection is as approved and safe. PR <br /> ❑ eds ds Repair* <br /> There are no insect or rodent infestations. �JOk <br /> ❑ R Needs Re air' <br /> Th;sewage system is functioning,with no surfacing wastewater or backup. kay <br /> ElN eds 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: 2"� JyQ <br /> NAME DATE TITLE <br /> EH 27-XX 9/29/2013 Dairy Farm Employee Housing <br />