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SAN AM I N Environmental Health Department <br /> COUNTY <br /> Ureotness 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: ry a -17,mPR#: <br /> LOCATION: I(eE& L. (7Ajvl fSCLL 5Cft5.3 L MAP DESIGNATION: <br /> HOUSING UNIT INFORMATION <br /> Address or identification number of unit: Ccwt t;C hl jkt,S C Date of Inspection: 2j7_ Z-7-C) <br /> Type of Housing Unit: 0 Single Family Dwelling ❑ Mobile Home ❑ Other: <br /> #Employees in Unit: Date Unit First Built or Installed: <br /> Electrical Power Provided By: Gas Provided by: r✓ �.�7 <br /> HOUSING UNIT INSPECTION <br /> Interior Ctlecklist Comments <br /> Unit has hot and cold running water. Okay <br /> ❑N eds Repair* <br /> Approved electrical power and gas fuel being supplied to Unit. [190kay <br /> ❑Needs Repair* <br /> Heater maintained in functioning and safe manner(No space/portable [)00kay <br /> heaters). ❑ Needs Repair* <br /> Doors and windows are accessible/operable to allow for safe exiting. kay <br /> ❑ Needs Repair* <br /> All rooms are clean and sanitary.No insect/rodent infestations present. Okay <br /> ❑Needs Repair* <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 jjOkay <br /> in working order. ❑Needs Repair* <br /> All wiring in safe,working order(no splices,exposed wires,uncovered outlets). i�Ok <br /> E] R Needs Re air* <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 /> ❑ Needs Repair* <br /> All floors,walls,ceilings are free from holes,are not sagging or buckling,have a0kay <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 /> ❑ N eds Repair* <br /> Exterior siding is maintained with no loose plaster,peeling paint,holes,etc. Okay <br /> ❑ N eds Repair* <br /> Stairways are safe with no rotting,deteriorating,or loose parts. Okay <br /> ElN eds Re air* <br /> Propane tank f as barrier protection and'No Smoking"signage. Okay <br /> ❑ N ids Repair* <br /> The trash cans are sufficient in size,have lids and are picked up weekly. -PQOkay <br /> ElNeeds Repair* <br /> The electrical panel is covered and protected from tampering. Okay <br /> ❑ Needs Re air* <br /> The gas fuel connection is as approved and safe. Okay <br /> ❑ ITeVds Repair* <br /> There are no insect or rodent infestations. POkay <br /> ❑ Needs Repair* <br /> The sewage system is functioning,with no surfacing wastewater or backup. Okay <br /> ❑ Needs Repair* <br /> *deeds Repair: Please specify date repairs to be completed.Any Building Permits required for repairs must be obtained and finaled. <br /> I certif�r 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: _ �. 2-17 -12 <br /> NAME DATE TITLE <br /> 1868 E. Hazelton Avenue Stockton, California 95205 1 T 209 468-34201 F 209 464-0138 1 www.sjcehd.com <br />