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S A N J O A Q U I N Environmental Health Department —COUNTY---- DAIRY FARM EMPLOYEE HOUSING ANNUAL PERMIT EXEMPTION SELF-AUDIT HOUSING INSPECTION CHECKLIST COMPLETE ONE CHECKLIST FOR EACH HOUSING UNIT FACILITY NAME: PR#: LOCATION: MAP DESIGNATION: HOUSING UNIT INFORMATION Address or identification number of unit: Date of Inspection: Type of Housing Unit: ❑Single Family Dwelling ❑Mobile Home ❑Other: #Employees in Unit: Date Unit First Built or Installed: Electrical Power Provided By: Gas Provided by: HOUSING UNIT INSPECTION Interior Checklist Comments Unit has hot and cold running water. ❑Okay ❑Needs Repair* _ Approved electrical power and gas fuel being supplied to Unit. ❑Okay ❑Needs Repair' Heater maintained in functioning and safe manner(No spacelportable heaters), []Okay ❑Needs Repair* Doors and windows are accessible/operable to allow for safe exiting. Okay ❑Needs Repair* All rooms are clean and sanitary.No Insect/rodent infestations present. []OkayElNeeds Repair* All appliances(stove,water heaters,air conditioning units,heaters)are []Okay properly vented strapped and are maintained in a safe,working order. ❑Needs Repair* All smoke and carbon monoxide detectors are present and tested to be shown []Okay in working order. ❑Needs Repair' All wiring in safe,working order(no splices,exposed wires,uncovered outlets). []Okay❑Needs Repair* All plumbing in safe,working order(no leaks,properly maintained). []Okay ❑Needs Repair* All counters,sinks,toilets,tubs,showers are working and in sanitary condition. []Okay[INeeds Repair- All floors,walls,ceilings are free from holes,are not sagging or buckling,have []Okay no water leaks and are dean and in good condition. ❑Needs Repair* Exterior Checklist Comments Roof is properly maintained with no holes,loose shingles,leaks,etc. []Okay ❑Needs Repair* Exterior siding is maintained with no loose plaster,peeling paint,holes,etc. ❑okay ❑Needs Repair* _ Stairways are safe with no rotting,deteriorating,or loose parts. ❑Okay ❑Needs Repair* _ Propane tank has barrier protection and"No Smoking'signage. ❑Okay ❑Needs Repair* The trash cans are sufficient in size,have lids and are picked up weekly. []Okay ❑Needs Repair*. The electrical panel is covered and protected from tampering. []Okay ❑Needs Repair* The gas fuel connection is as approved and safe. []Okay ElNeeds Repair* There are no insect or rodent infestations. []OkayElNeeds Repair* The sewage system is functioning,with no surfacing wastewater or backup. ❑Okay ❑Needs Repair' `Needs Repair:Pleasespecify date repairs to be completed.Any Building Permits required for repairs must be obtained and finaled. 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. SIGNED: -_--_�__-_ ---- DATE - TITLE 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com