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SAN JOAQUIN Environmental Health Department <br /> : COUNTY <br /> Greatness arorvs 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: — y. r <br /> jt1t..1s PR#: <br /> LOCATION: f y j ", { (�.� (, Ei�: L�,w �7 %S' yIYIAP DESIGNATION: <br /> HOUSING UNIT INFORMATION <br /> Address or identification number of unit: Date of Inspection: 01-c: <br /> Type of Housing Unit: ❑ Single Family Dwelling nO Mobile Home ❑ Other: <br /> #Employees in Unit: Date Unit First Built or Installed: j <br /> Electrical Power Provided By: 7 "� _ Gas Provided by: tbt t <br /> HOUSING UNIT INSPECTION <br /> Interior Checklist Comments <br /> Unit has hot and cold running water. kay <br /> ❑ Needs Repair- <br /> Approved <br /> e air'Approved electrical power and gas fuel being supplied to Unit. C3Dkay <br /> ❑Needs Repair* <br /> Heater maintained in functioning and safe manner(No space/portable nbkay <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. kay <br /> ❑ Needs Re air* <br /> All appliances(stove,water heaters,air conditioning units,heaters)are C90kay <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 MOkay <br /> in working order. ❑ Needs Repair* <br /> All wiring in safe,working order(no splices,exposed wires,uncovered outlets). okay <br /> E] Needs Repair* <br /> All plumbing in safe,working order(no leaks,properly maintained). Okay <br /> ❑ Needs Re air* <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 ❑Okay <br /> no water leaks and are clean and in good condition. M Needs Repair* &7i7ey"-' Flc6A C,.qq '/i <br /> /2r A /Z <br /> Exterior Checklist Comments .3;1311 ZcZ <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 Re air* <br /> Stairways are safe with no rotting,deteriorating,or loose parts. Okay <br /> ❑Needs Repair* <br /> Propane tank has barrier protection and"No Smoking"signage. Okay <br /> ❑ Needs Repair* <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. WOkay <br /> ❑ Needs Repair* <br /> The gas fuel ccnnection is as approved and safe. [,Okay <br /> ❑ Needs Repair* <br /> There are no insect or rodent infestations. [20kay <br /> ❑ Needs Repair* <br /> The sewage system is functioning,with no surfacing wastewater or backup. kay <br /> ❑ Needs Repair* <br /> *Feeds 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 /> SIGNED3 C: —1 r <br /> BY: <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 />