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� a "° Uc3ma ° SAN JOAQUIN Environmental Health Department <br /> - COUNTY- <br /> cgi, P Greatness grows here. <br /> DAIRY FARM EMPLOYEE HOUSING <br /> ANNUAL PERMIT EXEMPTION SELF-AUDIT HOUSING INSPECTION CHECKLIST <br /> COMPLETE ONE CHECKLIST FOR EACH HOUSING UNIT <br /> FACILITY NAME: 'Tom ;kw5 PR#: 'C�S 2 1.31 S <br /> LOCATION: tS(vS5, ST(-iNECnV L Ct- wJ COk 94510 MAP DESIGNATION: <br /> HOUSING UNIT INFORMATION <br /> Address or identification number of unit: i 5SWS 5TE;Vjt6oL V,• Date of Inspection: Z 112\ <br /> Type of Housing Unit: *Single Family Dwelling F Mobile Home ❑ Other: <br /> #Employees in Unit: I Date Unit First Built or Installed: 1990,5 <br /> Electrical Power Provided By: Gas Provided by: VA 5 1— <br /> HOUSING <br /> HOUSING UNIT INSPECTION <br /> Interior Checklist Comments <br /> Unit has hot and cold running water. ®Okay <br /> ❑Needs Repair* <br /> Approved electrical power and gas fuel being supplied to Unit. ®okay <br /> ❑ Needs Repair* <br /> Heater maintained in functioning and safe manner(No space/portable ®okay <br /> heaters). ❑ Needs Repair* <br /> Doors and windows are accessible/operable to allow for safe exiting. ®Okay <br /> ❑ Needs Re air* <br /> All rooms are clean and sanitary.No insect/rodent infestations present. Okay <br /> ❑ Needs Re air* <br /> All appliances(stove,water heaters,air conditioning units,heaters)are ®Okay <br /> properly vented,strapped and are maintained in a safe,working order. ❑ Needs Repair* <br /> All smoke and carbon monoxide detectors are present and tested to be shown CJOkay <br /> in working order. ❑ Needs Repair* <br /> All wiring in safe,working order(no splices,exposed wires,uncovered outlets). Okay <br /> [I Needs Repair* <br /> All plumbing in safe,working order(no leaks,properly maintained). ®okay <br /> ❑ Needs Repair* <br /> All counters,sinks,toilets,tubs,showers are working and in sanitary condition. ®Okay <br /> E] Needs Repair* <br /> All floors,walls,ceilings are free from holes,are not sagging or buckling,have [$Okay <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. Okay <br /> ❑Needs Repair* <br /> Exterior siding is maintained with no loose plaster,peeling paint,holes,etc. ®Okay <br /> ❑ Needs Repair* <br /> Stairways are safe with no rotting,deteriorating,or loose parts. [20ay <br /> ❑ Needs kRepair* <br /> Propane tank has barrier protection and"No Smoking"signage. ay <br /> ❑ Needs kRepair* <br /> The trash cans are sufficient in size,have lids and are picked up weekly. ®okay <br /> ❑ Needs Repair* <br /> The electrical panel is covered and protected from tampering. ®okay <br /> ❑ Needs Repair* <br /> The gas fuel connection is as approved and safe. WOkay <br /> ❑ Needs Repair* <br /> There are no insect or rodent infestations. [110ay <br /> ❑ Needs kRepair* <br /> The sewage system is functioning,with no surfacing wastewater or backup. Okay <br /> ❑ Needs Repair* <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 inspected the above noted unit and that the information provided is true and correct to the best of my knowledge. <br /> SIGNED <br /> BY: c 0WAI(-2- <br /> NAME DATE TITLE <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />