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} RECEIVED <br /> �Q„!N SAN JOAQUIN COUNTY JAN 2 8 2015 <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 ENVIRONMENTAL HEALTH <br /> Telephone: (209) 468-3420 Fax.(209)464-0138 Wets:www.sjgov.org/ehdpERMIT/SERVICES <br /> 6R` ®AIRY FARM EMPLOYEE HOUSING <br /> ANNUAL PERMIT EXEMPTION SELF-AUDIT HOUSING INSPECTION CHECKLIST <br /> COMPLETE ONE CHECKLIST FOR EACH: HOUSING UNIT <br /> FACILITY NAME: c4i-co� JD/Vf " PR#: <br /> LOCATION: I S C''N(-C,,t/L eC,4 tCr'v qS�ZMAP DESIGNATION: <br /> HOUSING UNIT INFORMATION <br /> Address or identification number of unit: 155q5 .n4 a Date of Inspection: j <br /> Type of Housing Unit: ❑ Single Family Dwelling [&Mobile Home ❑ Other: <br /> #Employees in Unit: I Date Unit First Built or Installed: <br /> Electrical Power Provided By: -7 Gas Provided by: S � <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. L50kay <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. Okay <br /> ❑Needs Repair' <br /> All rooms are clean and sanitary.No insect/rodent infestations present. ®Okay <br /> ElNeeds Repair* <br /> All appliances(stove,water heaters,air conditioning units,heaters)are properly vented, 9QOkay <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 180kay <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 MOkay <br /> leaks and are clean and in good condition. ❑ N eds Repair* <br /> Exterior Checklist Comments <br /> Roof is properly maintained with no holes,loose shingles,leaks,etc. DOkay R <br /> ❑Needs Repair' <br /> WOka <br /> Exterior siding is maintained with no loose plaster,peeling paint,holes,etc. ❑ Needs Repair' <br /> Stairways are safe with no rotting,deteriorating,or loose parts. eeokay <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. y <br /> ❑ Needs <br /> 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. ❑ Needs Repair' <br /> The sewage system is functioning,with no surfacing wastewater or backup. y <br /> ❑Needs <br /> 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 knowledg <br /> SIGNED BY: 24 4 zv-Z� WVt11j1*�' <br /> NAME DATE TITLE <br /> 11�n.Gn.m Cmnln„oc Hn„cinn <br />