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o UrN,ci SANPJ0AQu , N <br /> ' � ° Environmer tal _ Vt <br /> l� ; <br /> ."' —COUNTY— <br /> Greatness grows here. <br /> -- FEB 2 6 2020 <br /> DAIRY FARM EMPLOYEE HOUSING ENVIRONMENTAL HEALTH <br /> ANNUAL PERMIT EXEMPTION SELF-AUDIT HOUSING INSPECTION CHECREI131VIT/SERVICES <br /> COMPLETE ONE CHECKLIST FOR EACH HOUSING UNIT <br /> FACILITY NAME: r-j ';WAAiti PR#: <br /> LOCATION: 15(t35 CA g53ZV MAP DESIGNATION: <br /> HOUSING UNIT INFORMATION r <br /> Address or identification number of unit: J-1��S E Date of Inspection: Z/I I Lo2-L <br /> Type of Housing Unit: R Single Family Dwelling ❑ Mobile Home ❑ Other: <br /> #Employees in Unit: If Date Unit First Built or Installed: f jg s <br /> Electrical Power Provided By: Pb.*4� Gas Provided by: 4*04 S 7,-?ArJ . <br /> HOUSING UNIT INSPECTION <br /> Interior Checklist Comments <br /> Unit has hot and cold running water. ❑ Needsay <br /> Repair* <br /> Approved electrical power and gas fuel being supplied to Unit. 590kay <br /> ❑ Needs Repair* <br /> Heater maintained in functioning and safe manner(No space/portable (Okay <br /> heaters). ❑ 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. MOkay <br /> ElNeeds Repair* <br /> All appliances(stove,water heaters,air conditioning units,heaters)are ®Okay <br /> properly vented,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 NOkay <br /> in working order. ❑ Needs Repair* <br /> All wiring in safe,working order(no splices,exposed wires,uncovered outlets). ❑NeedskRe air* <br /> All plumbing in safe,working order(no leaks,properly maintained). Okay <br /> E] Needs Repair* <br /> All counters,sinks,toilets,tubs,showers are working and in sanitary condition. (Okay <br /> E] Needs Repair* <br /> All floors,walls,ceilings are free from holes,are not sagging or buckling,have C�Okay <br /> no water 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. kay <br /> ElNeeds Repair* <br /> Exterior siding is maintained with no loose plaster,peeling paint,holes,etc. okay <br /> ❑ Needs Repair* <br /> Stairways are safe with no rotting,deteriorating,or loose parts. EYOkay <br /> ❑Needs Repair* <br /> Propane tank has barrier protection and"No Smoking"signage. kay <br /> ❑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. [90ay <br /> ❑ Needs kRepair* <br /> The gas fuel connection is as approved and safe. [POkay <br /> ❑ Needs Repair* <br /> There are no insect or rodent infestations. okay <br /> ElNeeds Repair* <br /> The sewage system is functioning,with no surfacing wastewater or backup. LTOkay <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 <br /> BY: C.zt Z J L L' �iW/vt%Z <br /> \ NAME DATE TITLE <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />