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p,pUlM SAN .JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT RECEIVE® <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209) 468-3420 Fax: (209)464-0138 Web:www.sjgov.org/ehd JUL 3 0 2014 <br /> ;. <br /> q� FOR�,P DAIRY FARM EMPLOYEE HOUSING <br /> ANNUAL PERMIT EXEMPTION SELF-AUDIT HOUSING INSPECTION CI RQWENTALHEALTH <br /> COMPLETE ONE CHECKLIST FOR EACH HOUSING UNIT <br /> FACILITY NAME: PR#: <br /> LOCATION: Ci y,,, ki`-y" —CA 10A r Q" MAP DESIGNATION: <br /> HOUSING UNIT INFORMATION <br /> Address or identification number of unit: �,, �r� p at of Inspection: <br /> Type of Housing Unit: ❑ Single Family Dwelling Mobile Home Duplex❑ Dormitory ❑ Other: <br /> #Employees in Unit: Date Unit First Built or Installed: <br /> Electrical Power Provided By: VG- Gas Provided by: <br /> HOUSING UNIT INSPECTION <br /> Interior Checklist Comments <br /> EaKaUnit has hot and cold running water. <br /> ElR Needs Repair* <br /> Approved electrical power and gas fuel being supplied to Unit. 26k-ay <br /> ❑ Nee Repair* <br /> Heater maintained in functioning and safe manner(No space/portable heaters). El Okay <br /> Need Repair* <br /> Doors and windows are accessible/operable to allow for safe exiting. LjOkay <br /> ElNeed Repair* <br /> All rooms are clean and sanitary. No insect/rodent infestations present. kay <br /> ElNeeds Repair* <br /> All appliances(stove,water heaters,air conditioning units, heaters)are properly kay <br /> vented,strapped and are maintained in a safe,working order. ❑ Need Repair* <br /> All smoke detectors are present and tested to be shown in working order. okay <br /> ❑ Needs Repair* <br /> All wiring in safe,working order(no splices,exposed wires,uncovered outlets). [jTEl okay <br /> Needp Repair* <br /> All plumbing in safe,working order(no leaks, properly maintained). E40El Needs <br /> Needs Repair* <br /> All counters,sinks,toilets,tubs, showers are working and in sanitary condition. kay <br /> ❑ Nee Repair* <br /> All floors,walls,ceilings are free from holes,are not sagging or buckling, have 90kay <br /> no water 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 /> ElNeeds Repair* <br /> Exterior siding is maintained with no loose plaster,peeling paint,holes,etc. kay <br /> ❑ Need Repair* <br /> Stairways are safe with no rotting,deteriorating,or loose parts. kay <br /> EINee a air* <br /> Propane tank has barrier protection and"No Smoking"signage. okay <br /> E] Neep Repair* <br /> The trash cans are sufficient in size,have lids and are picked up weekly. okay <br /> ❑ Nee5lsRe air* <br /> The electrical panel is covered and protected from tampering. okay <br /> ❑ Nee Repair* <br /> The gas fuel connection is as approved and safe. okay <br /> ❑ Nee Repair* <br /> There are no insect or rodent infestations. o y <br /> El 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. 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: �� 'Z (-)( 9_") I <br /> NAME DATE TITLE <br /> EH 27-XX 4/27/2010 Dairy Farm Employee Housing <br />