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P�v,IN SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 2: •Z <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209) 468-3420 Fax: (209)464-0138 Web:www.sjgov.org/ehd <br /> Cq�iFORN�P <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: 1"1,4PR#: <br /> LOCATION: c MAP DESIGNATION: <br /> HOUSING UNIT INFORMATION <br /> Address or identification number of unit: 0 1 (V, ljVj S c„L Date of Inspection: <br /> Type of Housing Unit: ingle Family Dwelling ❑ Mobile Home ❑ Other: <br /> #Etnployees in Unit: Date Unit First Built or Installed: <br /> Electrical Ppwer Provided By: Gas Provided by: <br /> HOUSING UNIT INSPECTION <br /> Interior Checklist Comments <br /> Unit has hot and cold running water. Okay <br /> [INeed Repair* <br /> Approved electrical power and gas fuel being supplied to Unit. [90k <br /> El RR <br /> e air* <br /> Heater maintained in functioning and safe manner(No space/portable heaters), okay <br /> El Need Repair* <br /> Doors and windows are accessible/operable to allow for safe exiting. y <br /> C1 NeeOkaair` <br /> All rooms are clean and sanitary.No insect/rodent infestations present. Okay <br /> E]Need Repair* <br /> All appliances(stove,water heaters,air conditioning units,heaters)are properly vented, Okay <br /> strapped and are maintained in a safe,working order. ❑Needk Repair* <br /> All smoke and carbon monoxide detectors are present and tested to be shown in working Erokay <br /> order. ❑Need Repair* <br /> All wiring in safe,working order(no splices,exposed wires,uncovered outlets). ElOkay Nee Repair* <br /> All plumbing in safe,working order(no leaks,properly maintained). Okay <br /> ElNee Repair* <br /> All counters,sinks,toilets,tubs,showers are working and in sanitary condition. Okay <br /> ❑ Neeo Repair* <br /> All floors,walls,ceilings are free from holes,are not sagging or buckling,have no water E10kay <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. Okay <br /> ElNeed Repair* <br /> Exterior siding is maintained with no loose plaster,peeling paint,holes,etc. okay <br /> ElNee Repair* <br /> Stairways are safe with no rotting,deteriorating,or loose parts. Okay <br /> ElNee Re air` <br /> Propane tank has barrier protection and"No Smoking"signage. Okay <br /> ❑Nee Repair* <br /> ff <br /> The trash cans are sufficient in size,have lids and are picked up weekly. Okay <br /> ❑NeeOS Repair* <br /> The electrical panel is covered and protected from tampering. okay <br /> ElNee Re air* _ <br /> The gas fuel connection is as approved and safe. ❑NOkay ee Repair* <br /> There are no insect or rodent infestations, ❑NO y <br /> _ Nee Repair* <br /> The sewage system is functioning,with no surfacing wastewater or backup. okay <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 /> SIGNED BY: t, I Z—/ 5-1 <br /> NAME DATE TITLE <br /> EH 27-XX 9/20/2013 — Dairy Farm Employee Housing <br />