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SAN .IOAQUIN COUNTY RECEIVED ENVIRONMENTAL HEALTH DEPARTMENT l` C N C <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> ".1rVd Telephone: (209) 468-3420 Fax: (209) 464-0138 Web:www.sjgov.org/ehd JUL 3 0 2014 <br /> �'9C%FO,RC�P <br /> DAIRY FARM EMPLOYEE HOUSING ENVIRONMENTAL HEALTH <br /> ANNUAL PERMIT EXEMPTION SELF-AUDIT HOUSING INSPECTION CHECKLIgRMIT/SERVICES <br /> COMPLETE ONE CHECKLIST FOR EACH HOUSING UNIT <br /> EFAYNAME: PR#: <br /> N: 0\ VJp MAP DESIGNATION: <br /> HOUSING UNIT INFORMATION <br /> Address or identification number of unit: % W S Date of Inspection: <br /> Type of Housing Unit: R Single Family Dwelling ❑ Mobile Home Duplex❑ Dormitory ❑ Other: <br /> #Employees in Unit: fi 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. [Okay <br /> ❑ Needs Repair* <br /> Approved electrical power and gas fuel being supplied to Unit. okay <br /> ❑ Needs Repair* <br /> Heater maintained in functioning and safe manner(No space/portable heaters). kay - <br /> ❑ Needs Reair* <br /> Doors and windows are accessible/operable to allow for safe exiting. —kay -- <br /> ❑ Needs Repair* <br /> All rooms are clean and sanitary. No insect/rodent infestations present. Okay <br /> ❑ Nees Repair* <br /> All appliances(stove,water heaters,air conditioning units,heaters)are properly EjOkay <br /> vented, strapped and are maintained in a safe,working order, ❑ Needs 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). I Okay <br /> ❑ Nees Repair* <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 /> ❑ Needs Repair* <br /> All floors,walls,ceilings are free from holes,are not sagging or buckling, have -------[Yokay <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 /> ❑ <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. okay <br /> _ ❑ Need Repair* <br /> Propane tank has barrier protection and"No Smoking"signage. kay — - <br /> ❑ Nee s Repair* <br /> The trash cans are sufficient in size,have lids and are picked up weekly. okay <br /> ❑ Nee4s Repair* <br /> The electrical panel is covered and protected from tampering. E70kay <br /> ❑ Needs Repair* <br /> The gas fuel connection is as approved and safe. ❑okay <br /> ❑Needs Repair* <br /> There are no insect or rodent infestations. okay <br /> ❑ Needs Repair* <br /> The sewage system is functioning,with no surfacing wastewater or backup. kay <br /> Need s <br /> ElRepair* <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: L1 2 �_ I (/ �Y Cl S m CA <br /> NAME DATE TITLE <br /> EH 27-XX 4/271201&-JDairy Farm Employee liousing <br />