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PaDrN SAN JOAQUIN COUNTY RECEIVED <br /> ENVIRONMENTAL HEALTH DEPARTMENT UEC 1 1 2015 <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> ` Telephone:(209)468-3420 Fax: (209)464-0138 Web:www.sjgov.org/ehd 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: (PWJ14� PR#: <br /> LOCATION: ( 'zj f(-i-X6 -'iVL MAP DESIGNATION: <br /> HOUSING UNIT INFORMATION <br /> Address or identification number of unit: 'F j Date of Inspection: I Z f? 114, <br /> Type of Housing Unit: ❑ Single Family Dwelling M Mobile Home ❑ Other: <br /> #Employees in Unit: Z Date Unit First Built or Installed: <br /> Electrical Power Provided By: (_ Gas Provided by: ; S iLu,?•�v�' <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. [SOkay <br /> ❑ Needs Repair* <br /> ay <br /> Heater maintained in functioning and safe manner(No space/portable heaters). eR <br /> ❑ ds <br /> Needs Repair' <br /> Doors and windows are accessible/operable to allow for safe exiting. E60kay <br /> ❑ Needs Repair- <br /> All <br /> e air*All rooms are clean and sanitary.No insect/rodent infestations present. C40kay <br /> ❑ Needs Repair* <br /> All appliances(stove,water heaters,air conditioning units,heaters)are properly vented, QOkay <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. ❑ Needs Repair* <br /> All wiring in safe,working order(no splices,exposed wires,uncovered outlets). Wkay <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. kay <br /> Needs Repair* !t1 tr e- <br /> All floors,walls,ceilings are free from holes,are not sagging or buckling,have no water ❑Okay ( ZI-11 <br /> i5 <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. E�Qkay <br /> ❑ Needs Repair* <br /> Exterior siding is maintained with no loose plaster,peeling paint,holes,etc. CpOkay <br /> ❑ Needs Repair* <br /> Stairways are safe with no rotting,deteriorating,or loose parts. kay <br /> ❑ Needs Repair* <br /> Propane tank has barrier protection and"No Smoking"signage. QjDkay <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 /> [I Needs Repair* <br /> The gas fuel connection is as approved and safe. kay <br /> E] Needs Re air' <br /> There are no insect or rodent infestations. kay <br /> E] Needs Repair* <br /> The sewage system is functioning,with no surfacing wastewater or backup. Wkay <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 truce and correct to the best/of my knowledge <br /> SIGNED BY: 2-1 <br /> NAME DATE TITLE <br /> EH 27-XX 9/20/2013 Dairy Farm Employee Housing <br />