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SAN J 0 A Q U I N Environmental Health Department I COUNTY--- V, 131ECitrit:y5 gurou DAIRY FARM EMPLOYEE HOUSING ANNUAL PERMIT EXEMPTION SELF-AUDIT HOUSING INSPECTION CHECKLIST COMPLETE ONE CHECKLIST FOR EACH HOUSING UNIT FACILITY NAME: -ftt - + _ '� �t "�. PR#: LOCATION: ,j,,f 1 O 1),iljlp ' ' , Mqp pES1GNATION: HOUSING UNIT INFORMATION Address or identification number of unit: y., ) / 'tO Dpte 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: r7 ^; HOUSING UNIT INSPECTION Interior Checklist Comments Unit has hot and cold running water. jkay ❑Needs Re air* Approved electrical power and gas fuel being supplied to Unit. BOkay ❑Needs Repair* Heater maintained In functioning and safe manner(No spacelportable heaters). J20kay ❑Needs Re air` Doors and windows are accessible/operable to allow for safe exiting. kay ❑Needs Repair* All rooms are clean and sanitary.No Insect/rodent Infestations present. L20kay All appliances(stove,water heaters,air conditioning units,heaters are Needs ay air* properly vented strapped and are Maintained in a safe,workingordedk order. El Needs All smoke and carbon monoxide detectors are present and tested to be shown p0kay In working order. ❑Needs Repair* All wiring in safe,working order(no splices,exposed wires,uncovered outlets). J-20kay ❑Needs Repair* All plumbing in safe,working order(no leaks,properly maintained). L-j0kay ❑Needs Repair* All counters,sinks,toilets,tubs,showers are working and in sanitary condition. flOkay All floors,walls,ceilings are free from holes,are not sagging or buckling,have Needs Repel no water leaks and are clean and in good condition. 26kay ❑Needs Repair' Exterior Checklist — comments Roof is properly maintained with no holes,loose shingles,leaks,etc. Obkay ❑Needs Repair* Exterior siding is maintained with no loose plaster,peeling paint,holes,etc. pokey ❑Needs Repair' Stairways are safe with no rotting,deteriorating,or loose parts. I7Okay eeds Re air* Propane tank has barrier protection and'No Smoking"signage. WOkay ❑Needs Repair* The trash cans are sufncient in size,have lids and are picked up weekly. WOkay ❑Needs Re air* . The electrical panel is covered and protected from tampering. Wokay Needs Repair* The gas fuel connection is as approved and safe. Okay --------- ElNeeds Repair* There are no insect or rodent Infestations. DOkay Needs Re air* The sewage system is functioning,with no surfacing wastewater or backup. [20kay Needs Re air' *Needs Repair Pleasespecify date repairs to be com leted.Any Building Permits re uired for repairs must be obtained and finaled. I certify that I have Inspected thea ova noted unit and that the information provided Is true and correct to the best of my knowledge. SIGNED DAA TITLE 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 www.sjcehd.com