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Pa�,N SAN JOAQUIN COUNTY RECEIVED <br /> ENVIRONMENTAL HEALTH DEPARTMENT CEC 1 1 2015 <br /> �: fur - :< 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209)468-3420 Fax: (209)464-0138 Web:www.sjgov.org/ehd <br /> SSP ENVIRONMENTAL <br /> DAIRY FARM EMPLOYEE HOUSING HEALTH DEPARTMENT <br /> ANNUAL PERMIT EXEMPTION SELF-AUDIT HOUSING INSPECTION CHECKLIST <br /> COMPLETE ONE CHECKLIST FOR EACH HOUSING UNIT <br /> FACILITY NAME: PR#: <br /> LOCATION: L;'5� P PiSSZC7 MAP DESIGNATION: <br /> HOUSING UNIT INFORMATION <br /> Address or identification number of unit: Date of Inspection: vz('I 15 <br /> Type of Housing Unit: ❑ Single Family Dwelling 54 Mobile Home ❑ Other: <br /> #Employees in Unit: ' Date Unit First Built or Installed: j\)/A i c1 ei t,� <br /> Electrical Power Provided By: L� Gas Provided by: =j <br /> HOUSING UNIT INSPECTION <br /> Interior Checklist Comments <br /> Unit has hot and cold running water. kay <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). [30kay <br /> ❑ Needs Repair' <br /> Doors and windows are accessible/operable to allow for safe exiting. kay <br /> ❑ Needs Repair* <br /> All rooms are clean and sanitary.No insect/rodent infestations present. L�Okay <br /> ❑ 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 working I30kay <br /> order. ❑ Needs Repair' <br /> All wiring in safe,working order(no splices,exposed wires,uncovered outlets). kay <br /> ❑ Needs Repair' <br /> All plumbing in safe,working order(no leaks,properly maintained). Z?Okay <br /> ❑ Needs Repair' <br /> All counters,sinks,toilets,tubs,showers are working and in sanitary condition. U�Dkay <br /> ❑ Needs Repair* <br /> All floors,walls,ceilings are free from holes,are not sagging or buckling,have no water Mbkay <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 siding is maintained with no loose plaster,peeling paint,holes,etc. Nay <br /> eeds Repair* RC - i Z- c, 1 <br /> Stairways are safe with no rotting,deteriorating,or loose parts. ❑ 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. kay <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. kay <br /> ❑ Needs Repair* <br /> There are no insect or rodent infestations. MOkay <br /> ❑ Needs Repair' <br /> The sewage system is functioning,with no surfacing wastewater or backup. [)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: A� <br /> �1��►11"���11</Z- <br /> 'WAMe DATE TITLE <br /> EH 27-XX 9/2012013 Dairy Farm Employee Housing <br />