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rQU.1 SAN JOAQUIN COUNTY <br /> 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: 1 t ` PR#: <br /> LOCATION: `Iul Lw ,11w, I Co 62,A 7 MAP DESIGNATION: <br /> HOUSING UNIT INFORMATION <br /> Address or identification number of unit:k(c VA ;.r, Date of Inspection: <br /> Type of Housing Unit: 0 Single Family Dwelling ❑ Mobile dome ❑ Other: <br /> #Employees in Unit: I Date Unit First Built or Installed: <br /> Electrical Power Provided By: Gas Provided by: G E <br /> HOUSING UNIT INSPECTION <br /> Interior Checklist Comments <br /> Unit has hot and cold running water. E30kay <br /> ❑ Neecjs Repair* <br /> Approved electrical power and gas fuel being supplied to Unit. okay <br /> ❑ Nees Repair* <br /> Heater maintained in functioning and safe manner(No space/portable heaters). Okay <br /> ❑ Neem Repair <br /> Doors and windows are accessible/operable to allow for safe exiting. L00kay <br /> ❑Nee5s 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, gOkay <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 okay <br /> order, ❑ Needs Repair* j <br /> All wiring in safe,working order(no splices,exposed wires,uncovered outlets). Okay <br /> ❑Neeos Repair* <br /> All plumbing in safe,working order(no leaks,properly maintained). okay -— <br /> _ ❑ Needg 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 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 /> ❑ Neeot Repair* <br /> Exterior siding is maintained with no loose plaster,peeling paint,holes,etc, Okay r <br /> _ <br /> D Neeos Repair* <br /> Stairways are safe with no rotting,deteriorating,or loose parts. [ffOkay <br /> ❑ Neeos Repair* <br /> Propane tank has barrier protection and"No Smoking"signage. Okay <br /> D Needs Repair* _ <br /> The trash cans are sufficient in size,have lids and are picked up weekly. okay <br /> ❑ NeeO6 Repair* _ <br /> The electrical panel is covered and protected from tampering, Okay <br /> _ ❑ Nee0s Repair* <br /> The gas fuel connection is as approved and safe. Okay <br /> ❑ Neeo Repair* _ <br /> There are no insect or rodent infestations. okay <br /> ❑ Neeos 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 fi l ed. <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 k owledge. <br /> SIGNED BY: C. S( [►�( <br /> NAME DATE <br /> EH 27-XX 9/2012013 Dairy Farm Employs Housing <br />