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P4...l.y <br /> SAN JOAQUIN COUNTY RECEIVED <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> _ 1868 East Hazelton Avenue, Stockton, CA 95205-6232 JUL � p 2014 <br /> • Telephone. (209)468-3420 Fax:(209) 464-0138 Web:www.sjgov.org/ehd <br /> CQ�rF'OR�`P DAIRY FARM EMPLOYEE HOUSING ENVIRONMENTAL HEALTH <br /> ANNUAL PERMIT EXEMPTION SELF-AUDIT HOUSING INSPECTION CHECKLISTMITISERVICES <br /> COMPLETE ONE CHECKLIST FOR EACH HOUSING UNIT <br /> FACILITY NAME: 0`2 l Y u PR#: <br /> LOCATION: l iU` . `\ Ccs. G S`L MAP DESIGNATION: <br /> HOUSING UNIT INFORMATION 4pkW <br /> Address or identification number of unit: Date of Inspection: <br /> Type of Housing Unit: Rt Single Family Dwelling ❑ Mobile Home❑ Duplex❑ Dormitory ❑ Other: <br /> #Employees in Unit: Date Unit First Built or Installed: <br /> Electrical Power Provided By: Gas Provided by: yC ' <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. Q6kay <br /> ❑ NeecLs Repair* <br /> Heater maintained in functioning and safe manner(No space/portable heaters). okay — --T <br /> E] <br /> NeeJ6 Repair* <br /> Doors and windows are accessible/operable to allow for safe exiting. ED Neecis OkaRye air* <br /> All rooms are clean and sanitary. No insect/rodent infestations present. Okay <br /> ❑ Neep Repair* <br /> All appliances(stove,water heaters,air conditioning units,heaters)are properly Okay <br /> vented, strapped and are maintained in a safe,working order. ❑Nee5ls Repair* <br /> All smoke detectors are present and tested to be shown in working order. 00kay <br /> ❑ Neeos Repair* <br /> All wiring in safe,working order(no splices,exposed wires, uncovered outlets). ay <br /> ❑ Nee OkRepair* <br /> All plumbing in safe,working order(no leaks, properly maintained). okay <br /> ❑ Nee 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 90kay <br /> no water leaks and are clean and in good condition. _ ❑ Needs Repair* <br /> Exterior Checklist _--comments <br /> omments <br /> Roof is properly maintained with no holes, loose shingles, leaks,etc. kay <br /> (] Nee air* <br /> Exterior siding is maintained with no loose plaster,peeling paint, holes,etc. okay <br /> ❑ Nee Repair* <br /> Stairways are safe with no rotting,deteriorating,or loose parts. okay <br /> _ ❑ Nees Repair* <br /> Propane tank has barrier protection and"No Smoking"signage. Okay <br /> ❑ Need Repair* <br /> The trash cans are sufficient in size, have lids and are picked up weekly. Okay <br /> ❑Neeos Repair* <br /> The electrical panel is covered and protected from tampering. okay <br /> ❑Nees Repair* <br /> The gas fuel connection is as approved and safe. Okay <br /> ❑ Nees Repair* <br /> There are no insect or rodent infestations. MOkay <br /> ❑ Nee Re air* _ <br /> The sewage system is functioning,with no surfacing wastewater or backup. Okay <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 thelabove noted unit and that the information provided is true and correct to the best of my knowledge. <br /> SIGNED BY: V� YYN Qyl_ <br /> NAME DATE <br /> TITLE <br /> EH 27-XX 4/2712010 Dairy Farm Employee Housing <br />