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SAN JOAQUIN 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: p�"" � PR#: LOCATION: ,p.+s'/ ,- _ f MAP DESIGNATION: HOUSING UNIT INFORMATION Address or identification number of unit: Date of Inspection: Type of Housing Unit: ❑ Single Family Dwelling 14 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. kay ❑Needs Re air* _ Approved electrical power and gas fuel being supplied to Unit. Rtkay ❑Needs Repair* Heater maintained in functioning and safe manner(No spacelportable heaters), ❑Needs Repay air* Doors and windows are accessible/operable to allow for safe exiting. kay , ❑weeds Re air_ All rooms are clean and sanitary.No Insectfrodent Infestations present. Okay ❑Needs Repair* All appliances(stove,water heaters,air conditioning units,heaters)are Nmay 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 kay 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), kay _ ❑Needs Re air* All counters,sinks,toilets,tubs,showers are working and In sanitary condition. kay ❑Needs Repair* All floors,walls,ceilings are free from holes,are not sagging or buckling,have lkbkay no water leaks and are clean and in good condition. I ❑Needs Repair* Exterior Checklist Comments Roof is properly maintained with no holes,loose shingles,leaks,etc. J90ay ❑Needs kRepair* Exterior siding is maintained with no loose plaster,peeling paint,holes,etc. ay ❑Needs kRepair* Stairways are safe with no rotting,deteriorating,or loose parts. ❑Needs 00kRepay air* Propane tank has barrier protection and"No Smoking"sionage, kay ❑Needs Re air* 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, kay ❑Needs Repair* There are no insect or rodent Infestations. lWokay ❑Needs Repair* The sewage system Is functioning,with no surfacing wastewater o Rtkbackup, El Needs Repay air' *Needs R Pleasespecify date repdrrs t com leted.Any Building Permits required for repairs must be obtained and finaled. I certify,t4xei h e inspected the a noted d that the information provided is true and correct to the best of my knowledge. SIGNED: DATE TITLE 1V68 Hazelton Avenue I Stockton, California 952051 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com