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Pa„IN SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209) 468-3420 Fax: (209)464-0138 Web:www.sjgov.org/ehd <br /> c,FsR�'P 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 v`� PR#: <br /> LOCATION: q I MAP DESIGNATION: <br /> HOUSING UNIT INFORMATION <br /> Address or identification number of unit: ,. y� Date of Inspection: <br /> Type of Housing Unit: ❑ Single Family Dwelling obile HomeJ ❑ Other: <br /> #Employees in Unit: Date Unit First Built or Installed: <br /> Electrical Ppwer Provided By: r Gas Provided by: <br /> HOUSING UNIT INSPECTION <br /> Interior Checklist Comments <br /> Unit has hot and cold running water. lay <br /> [INeeds Repair* <br /> Approved electrical power and gas fuel being supplied to Unit. tray <br /> ❑ Need Re air* <br /> Heater maintained in functioning and safe manner(No space/portable heaters). kay <br /> ❑Needs Repair* <br /> Doors and windows are accessible/operable to allow for safe exiting. [20kay <br /> ❑Needs Repair* <br /> All rooms are clean and sanitary.No insect/rodent infestations present. kay <br /> ❑ Neecis Repair* <br /> All appliances(stove,water heaters,air conditioning units,heaters)are properly vented, Efolkay <br /> strapped and are maintained in a safe,working order. ❑ Need Repair* <br /> All smoke and carbon monoxide detectors are present and tested to be shown in working Mkay <br /> order. ❑Need epair* <br /> All wiring in safe,working order(no splices,exposed wires,uncovered outlets). kay <br /> ❑ Needs,Repair* <br /> All plumbing in safe,working order(no leaks,properly maintained). kay <br /> [:1 Nee Repair* <br /> All counters,sinks,toilets,tubs,showers are working and in sanitary condition, Okay <br /> ❑ Neecisr 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, okay <br /> ❑Nee Repair* <br /> Exterior siding is maintained with no loose plaster,pee!ing paint,holes.etc. Okay <br /> ❑Needk Repair' <br /> Stairways are safe with no rotting,deteriorating,or loose parts. Okay <br /> ❑Need a air* _ <br /> Propane tank has barrier protection and"No Smoking"signage. [30❑ Nee kayair* <br /> The trash cans are sufficient in size,have lids and are picked up weekly. Okay <br /> ❑Nee Repair* <br /> The electrical panel is covered and protected from tampering. Okay <br /> ❑ <br /> NeegiCRepair <br /> The gas fuel connection is as approved and safe. [21Okay <br /> ElNee Repair* <br /> There are no insect or rodent infestations. Ok <br /> qq <br /> ❑ Need a air' <br /> The sewage system is functioning,with no surfacing wastewater or backup, kay <br /> ❑ Needs Repair* <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 my knowledge. <br /> SIGNED BY: <br /> \J, <br /> NAME DATE TITLE <br /> EH 27-XX 9/20/20131t, Dairy Farm Employee Housing <br />