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PgU1N SAN.IOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> ��^�I��® <br /> 2: y <br /> N: <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 /> q .;FoDAIRY FARM EMPLOYEE HOUSING <br /> ENVIRONMENTAL HEALTH <br /> ANNUAL PERMIT EXEMPTION SELF-AUDIT HOUSING INSPECTION CHECKLISIERMIT/SF-RViCES <br /> COMPLETE ONE CHECKLIST FOR EACH HOUSING UNIT <br /> FACILITY NAME: �Y O PR#: <br /> LOCATION: k�Uti MAP DESIGNATION: <br /> HOUSING UNIT INFORMATION <br /> Address or identification number of unit:Uv\ w, 4\,( 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 <br /> nstalled:Electrical Power Provided By: Gas Provided by: r <br /> HOUSING UNIT INSPECTION <br /> Interior Checklist Comments <br /> Unit has hot and cold running water. okay <br /> [INeed Repair* <br /> Approved electrical power and gas fuel being supplied to Unit. GjOkay <br /> ElNee Re air* <br /> Heater maintained in functioning and safe manner(No space/portable heaters). okay <br /> ❑ Nee Repair* <br /> Doors and windows are accessible/operable to allow for safe exiting. okay <br /> ❑ Nee a air* <br /> All rooms are clean and sanitary. No insect/rodent infestations present. okay <br /> ❑ Nee Repair* <br /> All appliances(stove,water heaters,air conditioning units, heaters)are properly ff0kay <br /> vented,strapped and are maintained in a safe,working order. ❑ Needw Repair* <br /> All smoke detectors are present and tested to be shown in working order. okay <br /> El Nee Repair* <br /> All wiring in safe,working order(no splices,exposed wires,uncovered outlets). E] okay <br /> Nee Repair* <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 /> ElNeed Repair* <br /> All floors,walls,ceilings are free from holes, are not sagging or buckling, have kay <br /> no water leaks and are clean and in good condition. ❑ Needs Repair* <br /> Exterior Checklist Z Comments <br /> Roof is properly maintained with no holes, loose shingles, leaks,etc. okay <br /> E] Nee Re air* <br /> Exterior siding is maintained with no loose plaster,peeling paint,holes,etc. okay <br /> ElNee Repair* <br /> Stairways are safe with no rotting,deteriorating,or loose parts. okay <br /> [INee Repair* <br /> Propane tank has barrier protection and"No Smoking"signage. 2OkayNeeRepair* <br /> The trash cans are sufficient in size,have lids and are picked up weekly. Okay <br /> ElNee Re air* <br /> The electrical panel is covered and protected from tampering. okay <br /> [INee Repair* <br /> The gas fuel connection is as approved and safe. okay <br /> ElNee s Repair* <br /> There are no insect or rodent infestations. okay <br /> ElNee Repair* <br /> The sewage system is functioning,with no surfacing wastewater or backup. [Elokay <br /> El Need 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: , t YY\ <br /> NAME DATE TITLE <br /> EH 27-XX 4/27/2010 Dairy Farm Employee Housing <br />