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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> .y <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209) 468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd <br /> "�/PORN DAIRY FARM EMPLOYEE HOUSING <br /> ANNUAL PERMIT EXEMPTION SELF-AUDIT HOUSING INSPECTION CHECKLIST <br /> COMPLETE ONE CHECKLIST FOR EACH HOUSING UNIT <br /> FACILITY NAME: Ccts4elanedl,, OS. PR#: <br /> LOCATION: W1 W, ArM iris L,4#.% T$�YA MAP DESIGNATION: <br /> HOUSING UNIT INFORMATION <br /> Address or identification number of unit: Date of Inspection: /,2 <br /> Type of Housing Unit: N Single Family Dwelling ❑ Mobile Home ❑ Other: <br /> #Employees in Unit: Date'Unit First Built or Installed: <br /> Electrical PON/er Provided By: PCS qn0/ e- Gas Provided by: PG 4A <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). ®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 /> _ ❑Needs Repair* <br /> All appliances(stove,water heaters,air conditioning units,heaters)are properly vented, NOkay <br /> strapped and are maintained in a safe,working order. _ [I Needs Repair* <br /> All smoke and carbon monoxide detectors are present and tested to be shown in working V]Okay <br /> order. _ [I Needs Repair* <br /> All wiring in safe,working order(no splices,exposed wires,uncovered outlets). E]Okay <br /> ❑ Needs Repair* <br /> All plumbing in safe,working order(no leaks,properly maintained). JX]Okay <br /> [I 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 P90kay <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. [40kay <br /> -- _Needs Repair*—..--— — ---------—...-------— <br /> Exterior siding is maintained with no lease plaster,peeling paint.Holes,etc. Needs kuepa;r* <br /> Stairways are safe with no rotting,deteriorating,or loose parts. [POkay <br /> ❑ Needs Repair* <br /> Propane tank has barrier protection and'No Smoking'signage. 1SOkay <br /> ❑ Needs Repair* <br /> The trash cans are sufficient in size,have lids and are picked up weekly. I90kay <br /> ❑Needs Repair* <br /> The electrical panel is covered and protected from tampering. El Needs kayRepair* <br /> The gas fuel connection is as approved and safe. [19Okay <br /> ❑ Needs Repair* <br /> There are no insect or rodent infestations. [9Okay <br /> _ ❑ Needs Repair* <br /> The sewage system is functioning,with no surfacing wastewater or backup. MOkay <br /> [I Needs <br /> *Needs Repair: Pleasespecify 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 m knowledge. <br /> SIGNED BY: v 14 _0 —) <br /> NAME DATE TITLE <br /> EH 27-XX 9/20/2013 Dairy Farm Employee Housing <br />