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P'"Iry SAN JOAQUIN COUNTY <br /> c° 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: I r - PR#: <br /> LOCATION: `-(O� MAP DESIGNATION: <br /> HOUSING UNIT INFORMATION <br /> Address or identification number of unit:Yol (,u, Date of Inspection: <br /> Type of Housing Unit: 1216ingle Family Dwelling ❑ Mobil orae ❑ Other: <br /> #Employees in Unit: Date Unit First Built or Installed: <br /> Electrical Ppwer Provided By: :a Gas Provided by: C <br /> HOUSING UNIT INSPECTION <br /> Interior Checklist Comments <br /> Unit has hot and cold running water, kay <br /> ❑Needs Repair* <br /> Approved electrical power and gas fuel being supplied to Unit, kay <br /> ❑ Need Re air* <br /> Heater maintained in functioning and safe manner(No space/portable heaters). G10kay <br /> ❑ Needs Repair* <br /> Doors and windows are accessible/operable to allow for safe exiting. okay <br /> ❑ Needs Re air* <br /> All rooms are clean and sanitary.No insect/rodent infestations present. kay <br /> ❑ Need Repair* <br /> All appliances(stove,water heaters,air conditioning units,heaters)are properly vented, Mkay <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 907kay <br /> order. ❑ Need Repair' <br /> All wiring in safe,working order(no splices,exposed wires,uncovered outlets). Okay <br /> ❑ Need Repair* <br /> All plumbing in safe,working order(no leaks,properly maintained). Okay <br /> ❑ Neecjs Repair* <br /> All counters,sinks,toilets,tubs,showers are working and in sanitary condition. Okay <br /> ❑ Neels Repair* <br /> All floors,walls,ceilings are free from holes,are not sagging or buckling,have no water Okay <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. [10❑ Needs kRepair* <br /> Exterior sidingis maintained with no loose plaster,peeling Okay <br /> ' p p g paint,holes,etc. ❑ Ne2j§Repair* <br /> Stairways are safe with no rotting,deteriorating,or loose parts. Okay <br /> ❑ NeeK Repair* <br /> Propane tank has barrier protection and"No Smoking"signage, y <br /> ❑ Nee Okaair* <br /> The trash cans are sufficient in size,have lids and are picked up weekly. Okay <br /> ❑ Neefig 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 /> ❑ NeeRepair _ <br /> There are no insect or rodent infestations. Okay <br /> ❑Nees Repair* <br /> The sewage system is functioning,with no surfacing wastewater or backup. Okay <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 thb above noted unit and that the information provided is true and correct to the best of my knowledge. <br /> SIGNED BY: <br /> NAME DATE TITLE <br /> EH 27-XX 9/20/2013 Dairy Farm Employee Housing <br />