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N SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> bit <br /> Telephone: (209) 468-3420 Fax: (209)464-0138 Web: www.sjgov.org/ehd <br /> DAIRY FARM EMPLOYEE HOUSING <br /> f ANNUAL PERMIT EXEMPTION SELF-AUDIT HOUSING INSPECTION CHECKLIST <br /> ll COMPLETE ONE CHECKLIST FOR EACH HOUSING UNIT <br /> FACILITY NAME: 0 '\ (k YVA l O S PR#: <br /> LOCATION: VAtw• p I I MAP DESIGNATION: <br /> HOUSING UNIT INFORMATION <br /> Address or identification number of unit: �y. 1 ,j m A V_e� Date of Inspection: <br /> Type of Housing Unit: @#lSingle Family Dwelling Mobile Home ❑ Other: <br /> #Employees in Unit: It <br /> 7, Date Unit First Built or Installed: <br /> Electrical Power Provided By: Gas Provided by: <br /> HOUSING UNIT INSPECTION <br /> Interior Checklist Comments <br /> ❑ N <br /> Unit has hot and cold running water. - kay <br /> Needs Repair* <br /> Approved electrical power and gas fuel being supplied to Unit. ❑Nokay <br /> eed Re air* <br /> Heater maintained in functioning and safe manner(No space/portable heaters). okay <br /> ElNee Repair* <br /> Doors and windows are accessible/operable to allow for safe exiting. okayNeeds Re air* <br /> All rooms are clean and sanitary.No insect/rodent infestations present. Okay <br /> ElNeed Repair* <br /> All appliances(stove,water heaters,air conditioning units,heaters)are properly vented, 26kay <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 Q70kay <br /> order. [I Needs Repair* <br /> All wiring in safe,working order(no splices,exposed wires,uncovered outlets). okay <br /> E] Need a air" <br /> All plumbing in safe,working order(no leaks,properly maintained). ❑ Nkay <br /> ee Repair* <br /> All counters,sinks,toilets,tubs,showers are working and in sanitary condition, Okay <br /> E] Nee s Repair* <br /> All floors,walls,ceilings are free from holes,are not sagging or buckling,have no water EnOkay <br /> leaks and are clean and in good condition. ❑ Needs Repair* <br /> Exterior Checklist Comments <br /> ❑ Nee Re air" <br /> Roof is properly maintained with no holes,loose shingles,leaks,etc. Okay <br /> Exterior siding is maintained with no loose plaster,peeling paint,holes,etc. ❑ Neeos Re air* <br /> Stairways are safe with no rotting,deteriorating,or loose parts. okay <br /> ❑ Nee s Repair* <br /> Okay <br /> Propane tank has barrier protection and"No Smoking"signage. ❑ Needs Repair* <br /> ay <br /> The trash cans are sufficient in size,have lids and are picked up weekly. O R <br /> El Re air* <br /> Okay <br /> The electrical panel is covered and protected from tampering. ❑ Needs Repair* <br /> The gas fuel connection is as approved and safe. okay <br /> ❑ Nee s Re air* <br /> ay <br /> There are no insect or rodent infestations. O R <br /> ❑ Nee Re air" <br /> Okay <br /> The sewage system is functioning,with no surfacing wastewater or backup. ❑ 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 t4,above noted unit and that the information provided is true and correct to the best of my knowledge. <br /> SIGNED BY: G <br /> NAME DATE TITLE <br /> Eh 27-XX 9/20/2013 Dairy Farm Employee Housing <br />