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SAN J OA Q U I N Environmental Health Department <br /> .—COUNTY— <br /> DAIRY <br /> OUNTY--•-- <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: �~ '� "�,• PR#: <br /> LOCATION: , o i ,0i� t"' L� MAP DESIGNATION: <br /> HOUSING UNIT INFORMATION <br /> Address or identification number of unit: l `� <-� ) 4te of Inspection: - ' - <br /> Type of Housing Unit: ❑Single Family Dwelling /Mobile Home ❑Other: r <br /> #Employees in Unit: Date Unit First Built or Installed: <br /> Electrical Power Provided By: Gas Provided by: <br /> HOUSING UNIT INSPECTION <br /> Interior Checklist Comments <br /> Unit has hot and cold running water. - okay <br /> ❑Needs Re air* <br /> Approved electrical power and gas fuel being supplied to Unit. 20key <br /> ❑Needs Re air" <br /> Heater maintained in functioning and safe manner(No space/portable heaters). kay <br /> ❑Needs Repair, <br /> Doors and windows are accessible/operable to allow for safe exiting. (Okay <br /> ❑Needs Repair* <br /> All rooms are clean and sanitary.No Insect/rodent infestations present. 90-kay <br /> El Re <br /> All appliances(stove,water heaters,air conditioning units,heaters are Needs ay air* <br /> properlyvented straped and are maintained in a safe,workin order, ker. ❑Needs Repair* <br /> All smoke and carbon monoxide detectors are present and tested to be shown 13tkay <br /> in workin order. ❑Needs Repair* <br /> All wiring in safe,working order(no splices,exposed wires,uncovered outlets), 06kay <br /> ❑Needs Re air* <br /> All plumbing in safe,working order(no leaks,properly maintained), okay <br /> ❑Needs Repair <br /> All counters,sinks,toilets,tubs,showers are working and In sanitary condition. J70kay <br /> All floors,walls,ceilings are free from hales,are not sagging or buckling,have D Needs Repair* <br /> kay <br /> no water leaks and are clean and in good condition. Needs <br /> ❑Needs R <br /> Repair' <br /> Exterior Checklist <br /> Roof is properly maintained with no holes,loose shingles,leaks,etc. QOkay comments <br /> I]Needs Repair* <br /> Exterior siding is maintained with no loose plaster,peeling paint,holes,etc, 0Okay <br /> Needs Re air* <br /> Stairways are safe with no rotting,deteriorating,or loose parts. Okay <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, kay <br /> Eltfeeds Repair*. <br /> The electrical panel is covered and protected from tampering. j70kay <br /> Needs Repair* <br /> The gas fuel connection is as approved and safe. L�d>Jkay <br /> Needs Re air* <br /> There are no insect or rodent infestations, pOkay <br /> ❑Needs Re air* <br /> The sewage system is functioning,with no surfacing wastewater or backup. LjOkay <br /> ❑Needs Re air* <br /> Needs Repair Pleases ecif date re airs to be com leted.An Builth. Permits required for repairs must be obtained and finaied. <br /> 1 ce�Itha �have spected the above n ted unit and that the Information provided Is true and correct to the best of my knowledge. <br /> SIGNED: <br /> �,. <br /> DATE Tm e <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com ' <br />