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N N <br /> SAN 10 A Q U I N Environmental Health Department <br /> COUNTY <br /> x(F?(ytfl::St cr ov,'S nr;-e, <br /> DAIRY FARM EMPLOYEE HOUSING <br /> ANNUAL PERMIT EXEMPTION SELF-AUDIT HOUSING INSPECTION CHECKLIST <br /> COMPLETE ONE CHECKLIST cOR EACH HOUSING UNIT <br /> FACILITY NAME: o, ` LY05 PR#: <br /> LOCATION: 11,1 MAP DESIGNATION: <br /> f HOUSING UNIT INFORMATION <br /> Address or identification number of unit: pDate of Inspection: 7-45-101 <br /> Type of Housing Unit: Single Family Dwelling ❑Mobile Home ❑0ther: <br /> #Employees in Unit: Date Unit First Built or Installed: <br /> f Electrical Power Provided By: Gas Provided by: . <br /> iOUSING UNIT INSPECTION <br /> Interior Checklist Comments <br /> Unit has hot and cold running water. Okay <br /> ❑Needs Repair- <br /> Approved <br /> e airApproved dectrical power and gas fuel being supplied to Unit. kay <br /> ❑Needs Repair* <br /> Heater maintained in functioning and safe manner(No space/portable kay <br /> heaters). ❑Need Repair' <br /> Bb <br /> Doors and windows are accessible/operable to allow for safe exiting. �y <br /> E]N Repair' <br /> Okay <br /> All rooms are dean and sanitary.No insect/rodent infestations present. []Need Re air <br /> All appliances(stove,water heaters,air conditioning units,heaters)are Okay <br /> properly vented,2nW and are maintained in a safe,workin order. ❑N Repair- <br /> All <br /> epairAll smoke and carbon monoxide detectors are present and tested to be shown gOkay <br /> in working order. ❑Nesd epair- <br /> All wiring in safe,working order(no splices,exposed wires,uncovered outlets). ❑ a <br /> N Re air <br /> All plumbing in safe,working order(no leaks,properly maintained). Okay <br /> ❑ Repair' <br /> All counters,sinks,toilets,tubs,showers are working and in sanitary condition. Okay <br /> ❑Need Repair- <br /> All <br /> e itAll floors,walls,ceilings are free from holes,are not sagging or budding,have Mkay <br /> no water leaks and are dean and in good condition. ❑Needs Repair <br /> Exterior Checklist _ Comments <br /> Roof is propedy maintained with no holes,loose shingles,leaks,etc. ❑N[TOkay R air h <br /> Exterior siding is maintained with no loose plaster,peeling paint,holes,etc. y <br /> ❑Ne2o Repair* <br /> Stairways are safe with no rotting,deteriorating,or loose parts. okay <br /> ❑Need6 Re air <br /> Propane tank has barrier protection and'No Smoking'signage. Okay <br /> ❑ Repair* <br /> The trash cans are sufficient in size,have lids and are picked up weekly. uiltkay <br /> ❑ Repair* <br /> The electrical panel is covered and protected from tampering. <br /> 1210 <br /> ❑ Re air <br /> [19The gas fuel connection is as approved and safe. ❑ VR'e air- <br /> Them are no insect or rodent infestations. ❑ R air' <br /> The sewage system is functioning,with no surfacing wastewater or backup. y <br /> [�1Needs Repair* <br /> 'Needs Repair.Please specify date repairs to be completed_Any Building Permits required for reairs must be obtained and finaled. <br /> I certify lira!I have InspActed the above noted unit and that the lafomratim WWkI9d Is true end correct to the best of my knovA <br /> SIGNED �p,� <br /> BY: Vim" o T <br /> NAME <br /> 1868 Hazelt A nue I Stockton, California 952051 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />