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SAN JOAQUIN COUNTY <br /> .oG ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209) 468-3420 Fax: (209)464-0138 Web:www.sigov.org/ehd <br /> ,C 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: CA t Od VPq,,v-S j)p,i V--1 PR#: <br /> LOCATION: 1,5 �6 i��NCC��� eti Cq-Lc/j (�A MAP DESIGNATION: <br /> HOUSING UNIT INFORMATION <br /> Address or identification number of unit: IL�I�y �i 13CLt_ �C Date of Inspection: 7--2- <br /> Type <br /> ZType of Housing Unit: ® Single Family Dwelling ❑ Mobile Home ❑ Other: <br /> #Employees in Unit: it Date Unit First Built or Installed: /9 S C� <br /> Electrical Power Provided By: 7C- C Gas Provided by: <br /> HOUSING UNIT INSPECTION <br /> Interior Checklist Comments <br /> Unit has hot and cold running water. Okay <br /> ❑ Needs Repair* <br /> Approved electrical power and gas fuel being supplied to Unit. (Okay <br /> ❑ Needs 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. rQA§Okay <br /> ❑Needs Repair* <br /> All rooms are clean and sanitary.No insect/rodent infestations present. MOkay <br /> ❑Needs Re air* <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 ®Okay <br /> order. <br /> ❑Needs 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 /> ❑Needs Repair* <br /> All counters,sinks,toilets,tubs,showers are working and in sanitary condition. EyOkay <br /> ❑Needs Repair* <br /> All floors,walls,ceilings are free from holes,are not sagging or buckling,have no waterOkay <br /> leaks and are clean and in good condition. ElNeeds Repair* <br /> Exterior Checklist Comments <br /> Roof is properly maintained with no holes,loose shingles,leaks,etc. Okay <br /> - - -- ------ ---- ❑ Neds.Re Pair* <br /> Exterior siding is maintained with no loose plaster,peeling paint,holes,etc. Wkay - - <br /> ❑ Needs Re air* <br /> Stairways are safe with no rotting,deteriorating,or loose parts. [Okay <br /> Okay <br /> Re air* <br /> Propane tank has barrier protection and"No Smoking"signage. Okay <br /> ElN eds Repair* <br /> The trash cans are sufficient in size,have lids and are picked up weekly. ' Okay <br /> [:]Needs Re air* <br /> The electrical panel is covered and protected from tampering. [POkay <br /> ❑ Needs Repair* <br /> The gas fuel connection is as approved and safe. okay <br /> ❑ Needs Re air* <br /> There are no insect or rodent infestations. Okay <br /> Needs Re air* <br /> The sewage system is functioning,with no surfacing wastewater or backuETEDI <br /> Okay <br /> Needs Repair* <br /> *Needs Repair: Please specify 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: ZGJZ Lr,�q�E 7 G <br /> NAME DATE TITLE <br /> EH 27-XX 9/20/2013 <br />