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SAN J OAQ U I N Environmental (Health Department <br /> - COUNTY-­ <br /> DAIRY FARM EMPLOYEE MOUSING <br /> ANNUAL PERMIT EXEMPTION SELF-AUDIT HOUSING INSPECTION CHECKLIST <br /> COMPLETE ONE CHECKLIST FOR EACH HOUSING UNIT <br /> FACILITY NAME: ` PR#: <br /> LOCATION:�bj 1,LJ_ e t\ dMAP DESIGNATION: <br /> HOUSING UNIT INFORMATION <br /> Address or identification number of unit: Date of Inspection: <br /> Type of Housing Unit: Y Single Family Dwelling ❑ Mobile orae ❑ Other: <br /> #Employees in Unit: Date Unit First Built or Installed: <br /> Electrical Power Provided By: Gas Provided by: C <br /> OUSING UNIT INSPECTION _ <br /> Interior Checklist �— Comments <br /> Unit has hot and cold running water Okay <br /> ❑ Need Repair* <br /> Approved electrical power and gas fuel being supplied to Unit. Okay <br /> __ ❑ Nee Re air" <br /> Heater maintained n functioning and safe manner(No space/portable FrOkay <br /> heaters). El Needs Repair* <br /> Doors and windows are accessible/operable to allow for safe exiting. [;?Okay <br /> ElNee Repair` _ <br /> All rooms are clean and sanitary.No insect/rodent infestations present. Okay <br /> ❑ Needk Repair* _ <br /> All appliances(stove,water heaters,air conditioning units,heaters)are 210kay <br /> properly vented,strapped and are maintained in a safe,working order. ❑ Needs epair* <br /> All smoke and carbon monoxide detectors are present and tested to be shown 2tkay <br /> in working order. ❑ Need2 Repair* <br /> All wiring in safe,working order(no splices,exposed wires,uncovered outlets). kay <br /> _ El NeedA Repair. <br /> j <br /> All plumbing in safe,working order(no leaks,properly maintained). Okay <br /> El Need Repair* <br /> E20All counters,sinks,toilets,tubs,showers are working and in sanitary condition. kay — <br /> _ _ ❑ Need Re air* <br /> All floors,walls,ceilings are free from holes,are not sagging or buckling,have Mkay <br /> no water leaks and are clean and in good condition. ❑ Needs Repair* <br /> _Exterior Checklist Ir Comments <br /> Roof is properly maintained with no holes,loose shingles,leaks,etc. okay <br /> ❑ NeedXRe air* <br /> Exterior siding is maintained with no loose plaster,peeling paint,holes,etc. `�""'ay <br /> _ ❑ Nee Repair'___ _ <br /> Stairways are safe with no rotting,deteriorating,or loose pans. Okay <br /> ElNee a air* <br /> Propane tank has barrier protection and"No Smoking"signage. Okay <br /> El NeeRepair* <br /> The trash cans are sufficient in size,have lids and are picked up weekly. Okay <br /> ElNee s Repair* <br /> The electrical panel is covered and protected from tampering. Okay <br /> _ [:1 Neeo Repair* <br /> The gas fuel connection is as approved and safe. Okay <br /> ElNee Repair` <br /> There are no insect or rodent infestations. Okay <br /> 171Nee Repair* <br /> The sewage system is functioning,with no surfacing wastewater or backup. okay <br /> ❑ Needs Re air* <br /> *Needs Repair: Please specify date repairs to be completed.Any Building Permits required for repairs must be obtained and finaled. <br /> I certify that I have Ihspected the above noted unit and that the information provided is true and correct to the best of my knowledge. <br /> SIGNEDBY: 41n,4 <br /> NAME DATE TITLE <br /> 1f/E. Ha Ito Avenue Stockton, California 95205 1 T 209 468-3420 1 F 209464-0138 1 www.sjcehd.com <br />