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SANAOAQUIN Environmental Health Department COUNTY Greatness grows here. DAIRY FARM EMPLOYEE HOUSING ANNUAL PERMIT EXEMPTION SELF-AUDIT HOUSING INSPECTION CHECKLIST COMPLETE ONE CHECKLIST FOR EACH HOUSING UNIT FACILITY NAME: PR#: [ j LOCATION: Cig MAP DESIGNATION: HOUSING UNIT INFORMATION Address or identification number of unit: s-LS-j,S cx c (),j Date of Inspection: -1— Type of Housing Unit: PQ Single Family Dwelling ❑ Mobile Home ❑ Other: #Employees in Unit: I. Date Unit First Built or Installed: Electrical Power Provided By: Gas Provided by: IQ rt ft, jpQr d HOUSING UNIT INSPECTION Intwfortheeklist Comments Unit has hot and cold running water. okay ❑ Needs Repair* Approved electrical power and gas fuel being supplied to Unit. ®okay ❑ Needs Repair* Heater maintained in functioning and safe manner(No spacelportable heaters). eeOkay ❑Needs Repair* Doors and windows are accessible/operable to allow for safe exiting. ®okay ❑ Needs Repair* All rooms are dean and sanitary.No insectirodent infestations present. okay ❑Needs Repair* Ail appliances(stove,water heaters,air conditioning units,heaters)are ($Okay properly vented strapped and are maintained in a safe,working order. ❑Needs Repair* All smoke and carbon monoxide detectors are present and tested to be shown ROkay in working order. ❑Needs Repair* All wiring in safe,working order(no splices,exposed wires,uncovered outlets). [KOkay ❑Needs Repair* All plumbing in safe,working order(no leaks,properly maintained). Okay ❑ Needs Repair* Alf counters,sinks,toilets,tubs,showers are working and in sanitary condition. okay ❑Needs Repair- All e aiPAll floors,walls,ceilings are free from holes,are not sagging or buckling,have NOkay no water leaks and are clean and in good condition. ❑Needs Repair* Exterior Checklist Comments Roof is properly maintained with no holes,loose shingles,leaks,etc. Okay ❑Needs Repair* Exterior siding is maintained with no lom plaster,peeling paint,holes,etc. Okay ❑Needs Re air* Stairways are safe with no rotting,deteriorating,or loose parts. Okay ❑Needs Repair* Propane tank has barrier protection and'No Smoking'signage. [20kay ❑Needs Repair* The trash cans are sufficient in size,have lids and are picked up weekly. Okay ❑ Needs Repair* . The electrical panel is covered and protected from tampering. Okay ❑Needs Repair* The gas fuel connection is as approved and safe. ®Okay EI Needs Re air There are no insect or rodent infestations. okay ❑ N s Re air* The sewage system is functioning,with no surfacing wastewater or backup. Okay ❑Needs Repair* *Needs Re air.Please specify date repairs to be completed.Any Building Permits required for repairs must be obtained and finaled. I certify that I have Ins the above noted unit and that the information provided is true and correct to the best of my knowledge. SIGNED: DATE TmF 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com