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RECEIVED <br /> pPpUlry C SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT f Eli Z 8 201 <br /> !^= <I 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> MVIRONllAl.WAL 1,PA.LTH <br /> :•� Telephone: (209) 468-3420 Fax: (209) 464-0138 Web:www.sjgov.org/ehd F'EIT/SE �X5 <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: PR#: <br /> LOCATION: �7�'~7 5C /"�lw L 7 �( CfiC�f^� �'� MAP DESIGNATION: <br /> HOUSING UNIT INFORMATION <br /> Address or identification number of unit: Date of Inspection: z b (') <br /> Type of Housing Unit: ❑ Single Family Dwelling Mobile Home ❑ Other: <br /> #Employees in Unit: Date Unit First Built or Installed: jJ <br /> Electrical Power Provided By: L�:-t Gas Provided by: VAv'A i S <br /> HOUSING UNIT INSPECTION <br /> Interior Checklist Comments <br /> Unit has hot and cold running water. DjOkay <br /> ❑ Needs Repair* <br /> Approved 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 /> ❑ Needs Repair* <br /> Doors and windows are accessible/operable to allow for safe exiting. LXOkay <br /> ❑ Needs Repair* <br /> All rooms are clean and sanitary.No insect/rodent infestations present. Okay <br /> ❑ Needs Repair* <br /> All appliances(stove,water heaters,air conditioning units,heaters)are properly vented, JK Okay <br /> strapped and are maintained in a safe,working order. ❑ Needs Repair* <br /> All smoke and carbon monoxide detectors are present and tested be shown in working Okay <br /> WO <br /> order. ❑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. _ Okay <br /> 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 /> Exterior Checklist Comments <br /> Roof is properly maintained with no holes,loose shingles,leaks,etc. Okay <br /> ❑ Needs Repair* <br /> Exterior sidingIs maintained with no loose plaster,peeling ®Okay <br /> � p p g paint,holes,etc. <br /> ❑ Needs Repair* <br /> Stairways are safe with no rotting,deteriorating,or loose parts. BOkay <br /> ❑ 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 /> ❑ Needs Repair* <br /> The electrical panel is covered and protected from tampering. Okay <br /> ❑ Needs Repair* <br /> The gas fuel connection is as approved and safe. Okay <br /> ❑ Needs Repair* <br /> There are no insect or rodent infestations. D90kay <br /> ❑ Needs Repair* <br /> The sewage system is functioning,with no surfacing wastewater or backup. kay <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 m knowledge. <br /> SIGNED BY: ( "\ C" � �J� Z�I h °Vy'y%-` -1 <br /> NAME DATE TITLE <br /> EH 27-XX 9/20/2013 <br /> Dairy Farm Employee Housing <br />