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. ,,V , SAN JOAQUIN COUNTY <br /> Y <br /> ENVIROPdIil EN BAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stocl<ton, CA 95205-6232 <br /> ``_J: Telephone: (209) 468-3420 1=a;r: (209)464-0138 Wets:www.sjgov.org/ehd <br /> --�- <br /> © RY [fiA' Rhl EMPLOYEE <br /> MLOYEE M USp <br /> HG <br /> ANNUAL PERMIT EXI EMP T ION SELF-AUDIT HOUSING INSPECTION CHECKLIST <br /> COMPLETE ONE CHECKLIST FOR EACs. HOUSING UNIT _ <br /> FACILITY DAME: T::> Ce�1 c-vNl1-`�J_ PR#: <br /> LOCATION: I S (� �S 4A 5 I[SNC G ULIZc(. 61 1fJzC)MAP DESIGNATION: <br /> HOUSING UNIT INFORMATION <br /> Address or identification number of unit: �:W A Date of Inspection: I S <br /> Type of Housing Unit: ❑ Single Family Dwelling [XIViobile Home ❑ Other: <br /> #Employees in Unit: I Date Unit First Built or Installed: 1 cA G S <br /> Electrical Power Provided By: L, .IIr- Gas Provided by: LCP�M S <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. ($Okay <br /> ❑ Needs Repair' <br /> Heater maintained in functioning and safe manner(No space/portable heaters). kay <br /> ❑ Needs Repair' <br /> Doors and windows are accessible/operable to allow for safe exiting. C Ok <br /> E] Needs <br /> Needs Repair" <br /> All rooms are clean and sanitary.No insect/rodent infestations present. C90kay <br /> ❑Needs Repair' <br /> All appliances(stove,water heaters,air conditioning units,heaters)are properly vented, WOkay <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). Okay <br /> E] Needs Repair' <br /> ay <br /> All plumbing in safe,working order(no leaks,properly maintained). eR <br /> [I Needs <br /> eds 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 siding is maintained with no loose plaster,peeling paint,holes,etc. [91Okay <br /> ❑ Needs Repair* <br /> Stairways are safe with no rotting,deteriorating,or loose parts. okay <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 /> ay <br /> The electrical panel is covered and protected from tampering. R <br /> El NeBedseds Repair` <br /> The gas fuel connection is as approved and safe. ❑ Okay <br /> Needs Repair' <br /> There are no insect or rodent infestations. ❑ ,Okay <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 itis true and correct to the best of <br /> my lcnowledg <br /> SIGNED BY: n�Y��/` < 1 I I ) <br /> NAME DATE TITLE <br /> n­ c-,....❑mAn„oc P­.i­ <br />