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oa�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 /> FO DAIRY FARM EMPLOYEE HOUSING <br /> ANNUAL PERMIT EXEMPTION SELF-AUDIT HOUSING INSPECTION CHECKLIST <br /> COMPLETE ONE CHECKLIST FOR EACH HOUSING UNIT <br /> FACILITY NAME: Lj,- ell 11 6vc <" PR#: <br /> LOCATION: (4bl C6 2S2qZ MAP DESIGNATION: <br /> HOUSING UNIT INFORMATION <br /> Address or identification number of unit: �� ��L� <,, Ql� Date of Inspection: <br /> Type of Housing Unit: ❑ Single Family Dwelling Mobile Home ❑ Other: <br /> #Employees in Unit: 1 Date Unit First Built or Installed: <br /> Electrical Power Provided By: 6 Gas Provided by: " <br /> HOUSING UNIT INSPECTION <br /> Interior Checklist Comments <br /> Unit has hot and cold running water. kay <br /> ❑ Need a air* <br /> Approved electrical power and gas fuel being supplied to Unit. kay <br /> ❑ Needw Repair* <br /> Heater maintained in functioning and safe manner(No space/portable heaters). 62tkay <br /> ❑ NeedLg Repair* <br /> Doors and windows are accessible/operable to allow for safe exiting. Okay <br /> ❑Needs Repair* <br /> All rooms are clean and sanitary.No insect/rodent infestations present. 93'Okay <br /> ❑ Nded epair* <br /> All appliances(stove,water heaters,air conditioning units,heaters)are properly vented, ff0kay <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 Okay <br /> order. ❑ Need epair* <br /> All wiring in safe,working order(no splices,exposed wires,uncovered outlets). Okay <br /> ❑ Nee Re air* <br /> All plumbing in safe,working order(no leaks,properly maintained), okay <br /> __ ❑Neeo§Repair* <br /> All counters,sinks,toilets,tubs,showers are working and in sanitary condition. Okay <br /> ❑ Nee a air* <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 /> ❑ NeeO6 Repair* <br /> Exterior siding is maintained with no loose plaster,peeling paint,holes,etc. Okay <br /> _ ❑ Needs Repair* <br /> Stairways are safe with no rotting,deteriorating,or loose parts. Okay <br /> ❑ Need!,s Repair* <br /> Propane tank has barrier protection and"No Smoking"signage. Okay <br /> ❑ Nee Re air* <br /> The trash cans are sufficient in size,have lids and are picked up weekly. Okay <br /> ❑ Needs Repair* <br /> The electrical panel is covered and protected from tampering. okay <br /> ❑ Nee Re air* <br /> The gas fuel connection is as approved and safe. O y <br /> Nee Re air* <br /> El <br /> There are no insect or rodent infestations, Okay <br /> ❑ Nee 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 ins ected the above noted unit and that the information provided is truer and correct to the best of my knowledge. <br /> SIGNED BY: L`� j V <br /> AME DATE TITLE <br /> EH 27-XX 9/20/2013` J Dairy Farm Employee Housing <br />