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SAN JOAQUIN COUNTY <br /> PQM t N. <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> N: <br /> v ?� 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> ' Telephone:(209) 468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd <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: Cep"rj L+►f PR#: O 2 <br /> LOCATION: i,J� "+.L - IJ C: �s Ll MAP DESIGNATION: <br /> HOUSING UNIT INFORMATION <br /> Address or identification number of unit: �y�'Z (.11�►9 BLZL Date of Inspection: <br /> Type of Housing Unit: ®Single Family Dwelling ❑ Mobile Home ❑Other: <br /> #Employees in Unit: Date Unit First Built or Installed: y S p s <br /> Electrical Power Provided By: ,,• Gas Provided by: N ,fr <br /> HOUSING UNIT INSPECTION Comments <br /> Interior Checklist ®Okay <br /> Unit has hot and cold running water. ❑Needs Repair* <br /> jgOkay <br /> Approved electrical power and gas fuel being supplied to Unit. ❑ Needs Re air* <br /> WOkay <br /> Heater maintained in functioning and safe manner(No space/portable heaters). ❑Needs Re air* <br /> Okay <br /> Doors and windows are accessible/operable to allow for safe exiting. ElNeeds Re air* <br /> ®Okay <br /> All rooms are clean and sanitary.No insect/rodent infestations present. ❑ 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 workingEl Needsay <br /> order. 20kay <br /> All wiring in safe,working order(no splices,exposed wires,uncovered outlets). ❑Needs Repair* <br /> i2Okay <br /> All plumbing in safe,working order(no leaks,properly maintained). ❑Needs Repair* <br /> Okay <br /> All counters,sinks,toilets,tubs,showers are working and in sanitary condition. [I Needs Repair* <br /> All floors,walls,ceilings are free from holes,are not sagging or buckling,have no water E]NRepair*JvOk <br /> ay <br /> leaks and are clean and in good condition. Comments <br /> Exterior Checklist ®Okay <br /> Roof is properly maintained with no holes,loose shingles,leaks,etc. ❑Needs Re air* <br /> IROkay <br /> Exterior siding is maintained with no loose plaster,peeling paint,holes,etc. ❑Needs Re air* <br /> INOkay <br /> Stairways are safe with no rotting,deteriorating,or loose parts. ❑ Needs Re air* <br /> 110kay <br /> Propane tank has barrier protection and"No Smoking"signage. ❑Needs Re air* <br /> J@Okay <br /> The trash cans are sufficient in size,have lids and are picked up weekly. ❑Needs Re air* <br /> ®Okay <br /> The electrical panel is covered and protected from tampering. ❑ Needs Re air* <br /> `Okay <br /> The gas fuel connection is as approved and safe. ❑Needs Re air* <br /> kay <br /> There are no insect or rodent infestations. ❑Needs Re air* <br /> jg0kay <br /> The sewage system is functioning,with no surfacing wastewater or backup. ❑Needs Re air* <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 /> ?-/Z(5 )Z3 Efi--- <br /> SIGNED BY: �► DATE TITLE <br /> NAME <br /> Dairy Farm Employee Housing <br /> cu o�vv ommmniq .. _ .. ..._. .... <br />