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pP.Q,U SAN JOAQUIN COUNTY RECEIVED <br /> 2 G <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> K 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 /> F o RSP DAIRY FARM EMPLOYEE HOUSING ENVIRONMENTAL HEALTH <br /> ANNUAL PERMIT EXEMPTION SELF-AUDIT HOUSING INSPECTION CHECKLIS�ERMITISFRVIrFP <br /> COMPLETE ONE CHECKLIST FOR EACH HOUSING UNIT <br /> FACILITY NAME: 4 \ -VD ' PR#: <br /> LOCATION: o lr . p'V �,okZ MAP DESIGNATION: <br /> HOUSING UNIT INFORMATION <br /> Address or identification number of unit: o U, Y MS u+�c �a ate 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: (�, Gas Provided by: G <br /> HOUSING UNIT INSPECTION <br /> Interior Checklist Comments <br /> Unit has hot and cold running water. kay <br /> ❑ Need Repair* <br /> Approved electrical power and gas fuel being supplied to Unit. kay <br /> El Needs Need Repair* <br /> Heater maintained in functioning and safe manner(No space/portable heaters), ay <br /> _._ ❑ Nee Re air' <br /> Doors and windows are accessible/operable to allow for safe exiting. okay <br /> ❑ Neeo Repair* <br /> All rooms are clean and sanitary. No insecUrodent infestations present. okay <br /> ❑ <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. ❑ Need Repair* <br /> All smoke detectors are present and tested to be shown in working order. okay <br /> ❑ Needs Re air' <br /> All wiring in safe,working order(no splices,exposed wires,uncovered outlets). okay <br /> ❑ Nee ay air* <br /> All plumbing in safe,working order(no leaks, properly maintained). okay <br /> ❑Nee s Re air" <br /> All counters,sinks,toilets,tubs,showers are working and in sanitary condition. LOOkay <br /> ❑ NeecW Repair* <br /> All floors,walls,ceilings are free from holes,are not sagging or buckling,have EfOkay <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. kay <br /> _ ❑ Nee Re a_ir' <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 /> Needo Repair* <br /> Propane tank has barrier protection and"No Smoking"signage. LjUkay - <br /> ❑Nee Re air' <br /> The trash cans are sufficient in size,have lids and are picked up weekly. okay <br /> ❑Neecjs Repair* <br /> The electrical panel is covered and protected from tampering. okay <br /> ❑Nee Repair' <br /> The gas fuel connection is as approved and safe. 00kay - <br /> __ ❑ Neeos Repair* <br /> There are no insect or rodent infestations. LZOkay <br /> ❑Nee Repair* <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#ie above noted unit and that the information provided is true and correct to the best of my knowledge. <br /> SIGNED BY: 12= <br /> NAME <br /> DATE TITLE <br /> EH 27-XX 4/27/2010 <br /> Dairy Farm Employee Housing <br />