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pa U l f`! <br /> SAN JOAQUIN COUNTY RECEIVED <br /> F` ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 JUL 16 2014 <br /> Telephone: (209) 468-3420 Fax: (209)464-0138 Web:www.sjgov.org/ehd <br /> ENVIRONMENTAL HEALTH <br /> DAIRY FARM EMPLOYEE HOUSING PERMIT/SERVICES <br /> ANNUAL PERMIT EXEMPTION SELF-AUDIT HOUSING INSPECTION CHECKLIST <br /> COMPLETE ONE CHECKLIST FOR EACH HOUSING UNIT <br /> FACILITY NAME: PR#: <br /> LOCATION: 1 ei b ti/4 rti U V CF1, MAP DESIGNATION: <br /> HOUSING UNIT INFORMATION ko,,A< _ <br /> Address or identification number of unit: Date of Inspection: —7114 <br /> Type of Housing Unit: %Single Family Dwelling ❑ Mobile Home ❑ Other: <br /> #Employees in Unit: Date Unit First Built or Installed: /Q <br /> Electrical Power Provided By: C-11 E Gas Provided by: <br /> HOUSING UNIT INSPECTION <br /> Interior Checklist Comments <br /> ay <br /> Unit has hot and cold running water. � s R <br /> C1 Needs Repair* <br /> Approved electrical power and gas fuel being supplied to Unit. kay <br /> ElNeeds Repair* <br /> Heater maintained in functioning and safe manner(No space/portable heaters). ay❑ Needs Re air* <br /> Doors and windows are accessible/operable to allow for safe exiting. kay <br /> ❑ Needs Repair* <br /> All rooms are clean and sanitary. No insect/rodent infestations present. kay <br /> ElNeeds Repair* <br /> All appliances(stove,water heaters, air conditioning units, heaters)are properly Wkay <br /> vented,strapped and are maintained in a safe,working order. ❑ Needs Repair* <br /> All smoke detectors are present and tested to be shown in working order. ❑okay -112;0 <br /> eeds Repair* T t S <br /> All wiring in safe,working order(no splices,exposed wires,uncovered outlets). kay <br /> ❑ Needs Repair* <br /> All plumbing in safe,working order(no leaks,properly maintained). kay <br /> ElNe Repair* <br /> All counters,sinks,toilets,tubs,showers are working and in sanitary condition. <br /> E3Ne ds Repair* <br /> air* <br /> All floors,walls,ceilings are free from holes,are not sagging or buckling, have %okay <br /> no water 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. 5LOkay <br /> ❑ Needs Repair* <br /> Exterior siding is maintained with no loose plaster,peeling paint, holes,etc. kay <br /> ElNeeds Repair* <br /> Stairways are safe with no rotting,deteriorating,or loose parts. kay <br /> ElNeeds Repair* <br /> Propane tank has barrier protection and"No Smoking"signage. ®okay <br /> El Needs Repair* <br /> ay <br /> The trash cans are sufficient in size, have lids and are picked up weekly. eels R <br /> E] Needs Repair* <br /> The electrical panel is covered and protected from tampering. �Qk <br /> El <br /> Needs Repair* <br /> The gas fuel connection is as approved and safe. [okay <br /> ElNeeds Repair* <br /> There are no insect or rodent infestations. kay <br /> ElNeeds Repair* <br /> The sewage system is functioning,with no surfacing wastewater or backup. kay <br /> ElNeeds 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 knowledge. <br /> � <br /> SIGNED BY: &-v "� �req 11'I NIAAJA_(,-C- Z <br /> NAME DATE TITLE <br /> EH 27-XX 9/20/2013 Dairy Farm Employee Housing <br />