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SAN J OA Q U I N Environmental Health Department <br /> COUNTY— <br /> DAIRY <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: 1'7 PR#: <br /> LOCATION: + ) , 1• / MAP DESIGNATION: <br /> HOUSING UNIT INFORMATION <br /> Address or identification number of unit: 1 vte of Inspection: <br /> �5:JIB'. <br /> Type of Housing Unit: ❑ Single Family Dwelling El Mobile Home El Other: <br /> #Employees in Unit: Date Unit First Built or Installed: <br /> Electrical Power Provided By: Gas Provided by: + <br /> HOUSING UNIT INSPECTION y �� <br /> Interior Checklist <br /> Comments <br /> Unit has hot and cold running water. Okay <br /> ❑Needs Repair* <br /> Approved electrical power and gas fuel being supplied to Unit. Bt)kay <br /> ❑Need Re air' <br /> Heater maintained in functioning and safe manner(No space/portable heaters). ' okay <br /> ❑Needs Re air' <br /> Doors and windows are accessible/operable to allow for safe exiting, pokay <br /> ❑Needs Re air` <br /> All rooms are clean and sanitary.No insect/rodent infestations present. @Okay <br /> All appliances(stove,water heaters,air conditioning units,heaters are Needs 20kay air' <br /> goperlventeg,strapped and are maintained in a safe,working order. ❑Needs Repalr <br /> All smoke and carbon monoxide detectors are present and tested to be shown ©Okay — <br /> in workingorder. ❑Needs Repair* <br /> All wiring in safe,working order(no splices,exposed wires,uncovered outlets). 0Okay <br /> ❑Needs Repair* <br /> All plumbing in safe,working order(no leaks,properly maintained). [30kay <br /> ❑Needs Repair* <br /> All counters,sinks,toilets,tubs,showers are working and In sanitary condition. POkay <br /> All floors,walls,ceilings are free from holes,are not sagging or buckling,have Needs a <br /> ❑Needs <br /> Repair* <br /> no water leaks and are clean and In good condition. R <br /> eeds Repair• <br /> Exterior Checklist <br /> Roof Is property maintained with no holes,loose shingles,leaks,etc. [,Okay Comments <br /> ❑Needs Repair* <br /> Exterior siding is maintained with no loose plaster,peeling paint,holes,etc. L-JOkay <br /> Needs Repair* <br /> Stairways are safe with no rotting,deteriorating,or loose parts. WOkay <br /> ❑Needs Re air' <br /> Propane tank has barrier protection and"No Smoking"signage. Okay <br /> ❑Needs Repair* <br /> The trash cans are sufficient in size,have lids and are picked up weekly. ,W10kay <br /> ❑Needs Re air" . <br /> The electrical panel Is covered and protected from tampering. Okay <br /> ❑Needs Repair* <br /> The gas fuel connection Is as approved and safe. j]Okay <br /> ❑Needs Repair* <br /> There are no Insect or rodent infestations. WOkay <br /> ❑Needs Repair* <br /> The sewage system Is functioning,with no surfacing wastewater or backup, j.J0kay <br /> 11 Needs Re air* <br /> `Needs Repair Please s eci date repairs to 6e com leted.An Buildin Permits required for repairs must be obtained and finaled. <br /> 1 certify that I have Inspected the above noted unit and that the information provided Is true and correct to t <br /> SIGNED: he best of my knowledge. <br /> i L j <br /> DA,m Tine / <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-34201 F 209 464-0138 J vvww.sjcehd.com <br />