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�culr� c SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209) 468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd <br /> R_t.rksVz ®AIRY FARM EMPLOYEE HOUSING <br /> ANNUAL PERMIT EXEMPTION SELF-AUDIT HOUSING INSPECTION CHECKLIST <br /> COMPLETE ONE CHECKLIST FOR EACI: HOUSING UNIT <br /> FACILITY NAME: �• pPJ 17N PR#: <br /> LOCATION: a S ._�L�au L,ZA), Q CIA.9S310MAP DESIGNATION: <br /> HOUSING UNIT INFORMATION <br /> Address or identification number of unit: Date of Inspection: ZG I S <br /> Type of Housing Unit: ❑ Single Family Dwelling Mobile Home ❑ Other: <br /> #Employees in Unit: , Date Unit First Built or Installed: 196 S <br /> Electrical Power Provided By: Gas Provided by: 7S <br /> HOUSING UNIT INSPECTION <br /> Interior Checklist Comments <br /> ay <br /> Unit has hot and cold running water. R <br /> ❑Neeedsels 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). ®Okay <br /> ❑Needs Repair' <br /> Doors and windows are accessible/operable to allow for safe exiting. I�Ok <br /> El Needs <br /> Needs Re air' <br /> All rooms are clean and sanitary.No insect/rodent infestations present. ®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 (Okay <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. P§Okay <br /> ❑Needs Repair' <br /> All floors,walls,ceilings are free from holes,are not sagging or buckling,have no water qOkay <br /> leaks and are clean and in good condition. ❑Needs Repair' <br /> Exterior Checklist Comments <br /> Roof is property 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. Okay <br /> ❑Needs Repair' <br /> Stairways are safe with no rotting,deteriorating,or loose parts. okay <br /> ElNeeds 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 /> 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. kay <br /> ❑Needs Repair' <br /> The sewage system is functioning,with no surfacing wastewater or backup. $30kay <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 knowledg <br /> SIGNED BY: 0 IZE7 AV V;N/-C1 C�iZ <br /> NAME DATE TITLE <br /> n.,..,,a e"..nin„oo Nne�nn <br />