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0 ltq-- SAN .IOAQUIN COUNTY <br /> 4 <br /> N � ENVIRONMENTAL HEALTH DEPARTMENT <br /> i 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> ' Telephone: (209) 468-3420 Fax: (209)464-0138 Web:www.sjgov.org/ehd <br /> �Q.CfFOR�,\F <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 V.. PR#: <br /> LOCATION: ` W . MAP DESIGNATION: <br /> HOUSING UNIT INFORMATION <br /> Address or identification number of unit: ��,• mS� rl def Date of Inspection: <br /> Type of Housing Unit: Single Family Dwelling ❑ Mobile Home 13 ❑ Other: <br /> #Employees in Unit: L Date Unit First Built or Installed: <br /> Electrical Power Provided By: Gas Provided by: <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. okay <br /> ❑ Needp Re air* _ <br /> Heater maintained in functioning and safe manner(No space/portable heaters). E30kay <br /> ❑ Ne_e s Repair* <br /> Doors and windows are accessible/operable to allow for safe exiting. Okay <br /> ❑ <br /> Needs Repair* <br /> All rooms are clean and sanitary.No insect/rodent infestations present. 6k a— <br /> ay <br /> _❑ <br /> Weds 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. ❑ Needs Repair* <br /> All smoke and carbon monoxide detectors are present and tested to be shown in working Okay <br /> order. ❑ Need Repair* <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 /> ❑ <br /> Needs Repair* <br /> All counters,sinks,toilets,tubs,showers are working and in sanitary condition. Okay <br /> ❑ Needs Re air* <br /> _ <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. [XOkay <br /> ❑ Needs Repair* <br /> Exterior sidingis maintained with no loose plaster,peeling Okay <br /> ' p p g paint,holes,etc. ❑ Needs Repair* <br /> Stairways are safe with no rotting,deteriorating,or loose parts. L�rOkay <br /> ❑ Neeos Repair* <br /> Propane tank has barrier protection and"No Smoking"signage. [00❑ Need kayair* <br /> The trash cans are sufficient in size,have lids and are picked up weekly. kay <br /> _ ❑ Nee009 Re air* <br /> The electrical panel is covered and protected from tampering. Okay <br /> ❑ Nee s Repair* <br /> The gas fuel connection is as approved and safe. Okay <br /> ❑ Nee ,Repair* <br /> There are no insect or rodent infestations. Okay <br /> ❑ Neede`Re air* <br /> The sewage system is functioning,with no surfacing wastewater or backup. L21Okay <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 the above noted unit and that the information provided iis7 true and correct to the best of my knowledge. <br /> SIGNED BY: � `)' , e-1 <br /> NAME DATE TITLE <br /> EH 27-XX 9/20/201J✓' Dairy Farm Employee Housing <br />