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SAN ;J OA Q U I N Environmental Health Department <br /> —COUNTY— <br /> Greatness <br /> COUNTYGreatness 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: Prior. ikcLM5 PR#: <br /> LOCATION: I i, Zd CSC.�I� CA cf532C MAP DESIGNATION: <br /> HOUSING UNIT INFORMATION <br /> Address or identification number of unit: t ISN�,2 CA.?n(.-LL Date of Inspection: 2l IS I�1 <br /> Type of Housing Unit: [Single Family Dwelling ❑ Mobile Home ❑ Other: <br /> #Employees in Unit: Date Unit First Built or Installed: <br /> Electrical Power Provided By: p(, Gas Provided by: ^3/4 <br /> OUSING UNIT INSPECTION <br /> Interior Checklist Comments <br /> Unit has hot and cold running water. [Okay <br /> ❑ Needs Repair- <br /> Approved <br /> e air*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. C30kay <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 MOkay <br /> in working order. ❑ Needs Repair* <br /> All wiring in safe,working order(no splices,exposed wires,uncovered outlets). okay <br /> ❑ 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. NOkay <br /> ❑ Needs Repair* <br /> All floors,walls,ceilings are free from holes,are not sagging or buckling,have Nokay <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. ®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. Okay <br /> ❑ Needs Repair* <br /> The gas fuel connection is as approved and safe. [00kay <br /> ElNeeds Repair* <br /> There are no insect or rodent infestations. ®Okay <br /> ❑ Needs Repair* <br /> The sewage system is functioning,with no surfacing wastewater or backup. LJ�Dkay <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: cl <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 />