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SAN J OAQ U I N Environmental Health Department <br /> —COUNTY— <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: " A.„AJ to/ PR#: <br /> LOCATION: AP DESIGNATION: <br /> HOUSING UNIT INFORMATION- <br /> Address or identification number of unit: Date of Inspection: - ~ <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: Gas Provided by; <br /> HOUSING UNIT INSPECTION <br /> interior Checklist Comments <br /> Unit has hot and cold running water. Way <br /> _ ❑N ed Repair* <br /> Approved electrical power and gas fuel being supplied to Unit. kay <br /> ❑Nees Repair* <br /> Heater maintained in functioning and safe manner(No space/portable heaters), NeedsOkay air* <br /> Doors and windows are accessible/operable to allow for safe exiting. Kokay <br /> ❑Need Repair* <br /> All rooms are clean and sanitary.No Insect/rodent infestations present. kay --` <br /> _ El Needs Repair* _ <br /> All appliances(stove,water heaters,air conditioning units,heaters)are R6kay <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 290kay <br /> in working order, ❑Needs Repair* <br /> All wiring in safe,working order(no splices,exposed wires,uncovered outlets). JErOay <br /> ❑Nee kRe air* <br /> All plumbing in safe,working order(no leaks,properly maintained), k0kay <br /> ❑Needs Repair* <br /> All counters,sinks,toilets,tubs,showers are working and in sanitary condition. ❑ QOkNee s ay air• <br /> All floors,walls,ceilings are free from holes,are not sagging or buckling,have X01kay <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. kay <br /> ❑Needs Repair* <br /> Exterior siding is maintained with no loose plaster,peeling paint,holes,etc. ay <br /> El Needs kRe air* <br /> Stairways are safe with no rotting,deteriorating,or loose parts, MtkNeeds ay air• <br /> Propane tank has barrier protection and"No Smoking"signage, Wkay <br /> ❑Needs Re air' <br /> The trash cans are sufficient In size,have lids and are picked up weekly, kay <br /> ❑Needs Repair* . <br /> The electrical panel is covered and protected from tampering. 2rOkay <br /> ❑Needs Repair* <br /> The gas fuel connection is as approved and safe. Mkay <br /> ❑Needs Repair* <br /> There are no insect or rodent infestations. Okay <br /> 11 Neeo Re air" <br /> The sewage system Is functioring,with no surfacing wastewater or kup, WOkay <br /> ❑Needs Repair' <br /> *Needs ap<9Pleasespecify dateXpairs to omplated.Any Building Permits required for repairs must be obtained and finaled. <br /> 1 certify Qd t I e inspected the a ve note t and that the information provided Is true and correct to the best of my knowledge. <br /> SIGNED: <br /> _ DATE TITLE <br /> E, Hazelton Avenue I Stockton, California 952051 T 209 468-3420 1 F 209 464-0138 1 www.,.jcehd.com <br />