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SAN JOAQUIN COUNTY RECEIVED <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 JUL 3 0 2014 <br /> Telephone: (209) 468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd <br /> ENVIRONMENTAL HEALTH <br /> DAIRY FARM EMPLOYEE HOUSING PERMITISERVICES <br /> ANNUAL PERMIT EXEMPTION SELF-AUDIT HOUSING INSPECTION CHECKLIST <br /> COMPLETE ONE CHECKLIST FOR EACH HOUSING UNIT <br /> FACILITY NAME: 1 G' 0 1 16N e PR#: <br /> LOCATION: I 0� W. Ij}--r ,rvl I( r-(A. q5Z_c,2 MAP DESIGNATION: <br /> HOUSING UNIT INFORMATION <br /> Address or identification number of unit: , (��. Date of Inspection: <br /> Type of Housing Unit: ElSingle Family Dwelling © Mobile Home Duplex 17­1Dormitory ElOther: <br /> #Employees in Unit: 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). okay <br /> [I Needs 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. E]Okay <br /> ❑ Need Re air* <br /> All appliances(stove,water heaters,air conditioning units,heaters)are properly Okay <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. 6TOkay <br /> ❑ Nee Re air* <br /> All wiring in safe,working order(no splices,exposed wires, uncovered outlets), okay <br /> ❑ <br /> Neeos Repair* <br /> All plumbing in safe,working order(no leaks,properly maintained). [ffOkay "- <br /> ❑Ne <br /> eosRepair* <br /> All counters,sinks,toilets,tubs,showers are working and in sanitary condition. ay <br /> - ----- ❑ NRepair* <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 /> _ ❑ Nee Repair* <br /> Exterior siding is maintained with no loose plaster,peeling paint,holes,etc. okay - <br /> ❑ <br /> Neecjs Repair* <br /> Stairways are safe with no rotting,deteriorating,or loose parts. okay <br /> __. ❑ Nee05 Repair* <br /> Propane tank has barrier protection and"No Smoking"signage. Okay <br /> ❑ Neeo Repair* <br /> The trash cans are sufficient in size, have lids and are picked up weekly. LljOkay <br /> ❑ NeeA Repair* <br /> The electrical panel is covered and protected from tampering. okay - <br /> ❑NeeX 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 /> ❑ Nee Repair _ <br /> The sewage system is functioning,with no surfacing wastewater or backup. IOkay <br /> ❑ Needs Re air* <br /> 'Needs Repair: Pleasespecify 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: ftI— <br /> __ <br /> ���� ( Y(?I S v�tl�✓1 <br /> NAME DATE <br /> TITLE <br /> i <br /> EH 27-XX 4127/2010 J - Dairy Farm Employee Housing <br />