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Pa°IN SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> N 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: b-^ G j PR#: <br /> LOCATION: J •jp�5 STI' � _►v A a C 1N v L.-j C4 MAP DESIGNATION: <br /> HOUSING UNIT INFORMATION <br /> Address or identification number of unit: - zN LC-,V., A Date of Inspection: ­7 b L4 I i-i <br /> Type of Housing Unit: OSingle Family Dwelling +Mobile Home El Other: <br /> #Employees in Unit: 1 Date Unit First Built or Installed: <br /> Electrical Power Provided By: C'1 -,�r C Gas Provided by: VAp S `,?jZo AW <br /> HOUSING UNIT INSPECTION <br /> Interior Checklist Comments <br /> Unit has hot and cold running water. [Okay <br /> ElNeeds Repair* <br /> ay <br /> Approved electrical power and gas fuel being supplied to Unit. eR <br /> El Needs eds 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. kay <br /> ElNeeds Repair* <br /> All rooms are clean and sanitary. No insect/rodent infestations present. JZ]Okay <br /> ❑ Needs Repair* <br /> All appliances(stove,water heaters,air conditioning units, heaters)are properly k,Okay <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 <br /> ElNeeds Repair* <br /> All wiring in safe,working order(no splices,exposed wires,uncovered outlets). kay <br /> ElNeeds Repair* <br /> All plumbing in safe,working order(no leaks, properly maintained). kay <br /> ElNeeds Repair* <br /> fZ <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 90kay <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. okay <br /> ElNeeds Repair* <br /> Exterior siding is maintained with no loose plaster,peeling paint,holes,etc. okay <br /> ElNeeds Repair* <br /> Stairways are safe with no rotting,deteriorating,or loose parts. 6(ok <br /> El <br /> Needs Re air* <br /> Propane tank has barrier protection and"No Smoking"signage. El Need <br /> ds Repair* <br /> ay <br /> The trash cans are sufficient in size, have lids and are picked up weekly. R <br /> El Needs eds Repair <br /> The electrical panel is covered and protected from tampering. ElNeeds Repair* <br /> The gas fuel connection is as approved and safe. El Need s Repair* <br /> There are no insect or rodent infestations. kay <br /> [INeeds Repair* <br /> The sewage system is functioning,with no surfacing wastewater or backup. kay <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 myknowledge. <br /> SIGNED BY: ( '� � hii 1 <br /> NAME DATE TITLE <br /> EH 27-XX 9/20/2013 Dairy Farm Employee Housing <br />