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SAN JOAQUIN COUNTY RECEIVED <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> v ?{ 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> .. Telephone:(209) 468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd FEB 2 3 2023 <br /> -6 DAIRY DAIRY FARM EMPLOYEE HOUSING ENVIRONMENTALHEALT:-I <br /> ANNUAL PERMIT EXEMPTION SELF-AUDIT HOUSING INSPECTION CHECKH6IRM <br /> COMPLETE ONE CHECKLIST FOR EACH HOUSING UNIT <br /> FACILITY NAME: rpervr3 FpdUA4 PR#: v S IS <br /> LOCATION: K0 4 511,rJt 0v 1r, Ell AL"jgS12 C) MAP DESIGNATION: <br /> HOUSING UNIT INFORMATION <br /> Address or identification number of unit: Ilj�ji j S�E,we& 1r Date of Inspection: Z Z <br /> Type of Housing Unit:ASingle Family Dwelling 0 Mobile Home ❑ Other: <br /> #Employees in Unit: i Date Unit First Built or Installed: IGI C 5 <br /> Electrical Power Provided By: VG A E Gas Provided by: V- M 17 <br /> HOUSING UNIT INSPECTION <br /> Comments <br /> Interior Checklist <br /> ®Okay <br /> Unit has hot and cold running water. ❑Needs Repair* <br /> ®Okay <br /> Approved electrical power and gas fuel being supplied to Unit._ ❑ Needs Repair* <br /> ®Okay <br /> Heater maintained in functioning and safe manner(No space/portable heaters). ❑Needs Repair* <br /> WOkay <br /> Doors and windows are accessible/operable to allow for safe exiting. ❑Needs Repair* <br /> ®Okay <br /> All rooms are clean and sanitary.No insect/rodent infestations present. ❑ 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 workingEl Needsay <br /> Repair* <br /> order. M Okay <br /> All wiring in safe,working order(no splices,exposed wires,uncovered outlets). ❑Needs Repair* <br /> Okay <br /> All plumbing in safe,working order(no leaks,properly maintained). [I Needs Repair* lyi �R t.t�9` i0.Tti�K=� 2-1 bC, <br /> ®Okay <br /> All counters,sinks,toilets,tubs,showers are working and in sanitary condition. ❑Needs Repair* <br /> All floors,walls,ceilings are free from holes,are not sagging or buckling,have no water ®Okay <br /> leaks and are clean and in good condition. ❑Needs Repair* <br /> Comments <br /> Exterior Checklist <br /> ay <br /> Roof is properly maintained with no holes,loose shingles,leaks,etc. :�FO_]�Ne!edsRe air*ay <br /> Exterior siding is maintained with no loose plaster,peeling paint,holes,etc. ❑Needs Repair' <br /> kay <br /> Stairways are safe with no rotting,deteriorating,or loose parts. ❑Needs Repair* <br /> kay <br /> Propane tank has barrier protection and"No Smoking'signage. ❑ Needs Repair* <br /> Okay <br /> The trash cans are sufficient in size,have lids and are picked up weekly. ❑Needs Repair* <br /> Okay <br /> The electrical panel is covered and protected from tampering. ❑ Needs Repair* <br /> Okay <br /> The gas fuel connection is as approved and safe. ❑Needs Repair* <br /> Okay <br /> There are no insect or rodent infestations. ❑Needs Re air* <br /> Okay <br /> =Thes=ewage is functioning,with no surfacing wastewater or backup. ❑ Needs Re air* <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 knowled e. <br /> �,� Z I wiz <br /> SIGNED BY:BY: TITLE <br /> NAME DATE <br /> Dairy Farm Employee Housing <br />