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SAN 1 OA Q U I N Environmental Health Department ----COUNTY tslE';rti.:y; tjrnivs +1t'::: DAIRY FARM EMPLOYEE HOUSING ANNUAL PERMIT EXEMPTION SELF-AUDIT HOUSING INSPECTION CHECKLIST COMPLETE ONE CHECKLIST FOR EACH HOUSING UNIT FACILITY NAME: Or-4- ,* Vie,, PR#: LOCATION: ' i ` : ' i" ' :+� v 611 •:"+''- MAP DESIGNATION: HOUSING UNIT INFORMATION Address or identification number of unit:,5- , pate of Inspection: c Type of Housing Unit: aSingle Family Dwelling ❑ Mobile Home El 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. aOkay ❑Needs Re air" Approved electrical power and gas fuel being supplied to Unit. EJOkay ❑Needs Repair* Heater maintained in functioning and safe manner(No spacelportable heaters), F kay ❑Needs Repel Doors and windows are accessible/operable to allow for safe exiting. [QOkay ❑Needs Re air' All rooms are clean and sanitary.No insecl/rodent infestations present. Okay ❑Needs Repair* All appliances(stove,water heaters,air conditioning units,heaters)are 00kay 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 )30kay - in working order. ❑Needs Repair' All wiring in safe,working order(no splices,exposed wires,uncovered outlets), [20kfRepair* ❑Needs All plumbing in safe,working order(no leaks,properly maintained). LdOk ❑Needs All counters,sinks,toilets,tubs,showers are working and in sanitary condition. Ok All floors,walls,ceilings are free from holes,are not sagging or buckling,have NeedOsk no water leaks and are clean and in good condition. ee y El Repair" Exterior Checklist Roof is properly maintained with no holes,loose shingles,leaks,etc. ❑Okay Comments ❑Needs Repair* Exterior siding is maintained with no loose plaster,peeling paint,holes,etc. .J_!Okay ❑Needs Re air" Stairways are safe with no rotting,deteriorating,or loose parts, POkay ❑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 ❑NV e air*. The electrical panel is covered and protected from tampering. y ❑Ne air* The gas fuel connection is as approved and safe. y ❑Needs Repair* There are no insect or rodent Infestations. ❑okay Needs Re air* The sewage system is functioning,with no surfacing wastewater or backup, ❑Okay ❑Needs Re air" "Needs Repair.Pleasespecify date repairs to be completed.Any BuIldinq Permits required for repairs must be obtained and finaled. I certify that I:have Inspected the abo a noted unit and that the information provided Is true and correct to the best of m knowledge. SIGNED: s DATE TITLE I 1868 E. Hazelton Avenue I Stockton, California 952051 T 209 468-34201 F 209 464-0138 1 www.sjcehd.com