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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> ir\ <br /> < 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> ��,,,yr Telephone: (209) 468-3420 Fax: (209)464-0138 Web:www.sjgov.org/ehd <br /> FORS DAIRY FARM EMPLOYEE HOUSING <br /> ANNUAL PERMIT EXEMPTION SELF-AUDIT HOUSING INSPECTION CHECKLIST <br /> COMPLETE ONE CHECKLIST FOR EACH HOUSING UNIT <br /> FACILITY NAME: �/� PR#: <br /> LOCATION: L.-U f�/._- C14- !01 4/1h 57'fV J <br /> MAP DESIGNATION: <br /> HOUSING UNIT INFORMATION <br /> Address or identification number of unit: ,2 S(4 1(/ Date of Inspection: 1 27 <br /> Type of Housing Unit: 'k] Single Family Dwelling ❑ Mobile Home ❑ Other: <br /> #Employees in Unit: J Date Unit First Built or Installed: <br /> Electrical Power Provided By: C(� Gas Provided by: P <br /> HOUSING UNIT INSPECTION <br /> Interior Checklist Comments <br /> Unit has hot and cold running water. 00kay <br /> ❑ Needs Repair* <br /> Approved electrical power and gas fuel being supplied to Unit. ]Okay <br /> ElNeeds Repair* <br /> Heater maintained in functioning and safe manner(No space/portable heaters). I20kay <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 insecUrodent infestations present. ®Okay <br /> ElNeeds Repair* <br /> All appliances(stove,water heaters,air conditioning units,heaters)are properly vented, 1B0kay <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 (20kay <br /> order. ❑ Needs Repair* <br /> All wiring in safe,working order(no splices,exposed wires,uncovered outlets). Z[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. 90kay <br /> ❑ Needs Repair* <br /> All floors,walls,ceilings are free from holes,are not sagging or buckling,have no water [30kay <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 /> [INeeds Repair* <br /> Exterior siding is maintained with no loose plaster,peeling paint,holes,etc. ROkay <br /> ❑Needs Repair* <br /> Stairways are safe with no rotting,deteriorating,or loose parts. SOkay <br /> [INeeds Repair* <br /> Propane tank has barrier protection and"No Smoking"signage. Okay <br /> E] Needs 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. [I Needs Repayair* <br /> The gas fuel connection is as approved and safe. Okay <br /> ElNeeds Repair* <br /> There are no insect or rodent infestations. (10kay <br /> ❑ Needs Repair* <br /> The sewage system is functioning,with no surfacing wastewater or backup. 00kay <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 /> Id 71d <br /> NAME DATE TITLE <br /> EH 27-XX 9/20/2013 Dairy Farm Employee Housing <br />