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f SAN JOAQUIN Environmental Health Department ---COUNTY-- ��,ros1as neatness grows here. DAIRY FARM EMPLOYEE HOUSING ANNUAL PERMIT EXEMPTION SELF-AUDIT HOUSING INSPECTION CHECKLIST COMPLETE ONE CHECKLIST FOR EACH HOUSING UNIT FACILITY NAME: Pt on) ENtLA S PR#: G� 7It LOCATION: t 5(03 5 Va .v CA '1`75W MAP DESIGNATION: HOUSING UNIT INFORMATION Address or identification number of unit: 1554 5 SWat6ks_ Date of Inspection: Z 110 12 (,0 Type of Housing Unit: ❑ Single Family Dwelling w Mobile Home ❑Other: #Employees in Unit: Date Unit First Built or Installed: lqqs Electrical Power Provided By: (a d-E Gas Provided by: 14 V"P5 -PP"42L)f— HOUSING UNIT INSPECTION Interior Checklist Comments Unit has hot and cold running water. ®Okay ElNeeds Repair* Approved electrical power and gas fuel being supplied to Unit. ®okay ❑Needs Repair* Heater maintained in functioning and safe manner(No space/portable heaters). ®okay �✓1"T El Needs Repair W6 1fexp40 Doors and windows are accessible/operable to allow for safe exiting. ®okay ❑Needs Repair* All rooms are clean and sanitary.No insect/rodent infestations present, okay ❑Needs Repair* All appliances(stove,water heaters,air conditioning units,heaters)are ®Okay properlyvented,strapped and are maintained in a safe,working order. ❑Needs Repair* All smoke and carbon monoxide detectors are present and tested to be shown ®Okay 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). okay ❑Needs Repair* All counters,sinks,toilets,tubs,showers are working and in sanitary condition. okay ❑Needs Repair' All floors,walls,ceilings are free from holes,are not sagging or buckling,have [@Okay no water leaks and are clean and in good condition. ❑Needs Repair* Exterior Checklist Comments Roof is properly maintained with no holes,loose shingles,leaks,etc. ©okay ❑Needs Repair* Exterior siding is maintained with no loose plaster,peeling paint,holes,etc. El Needs Repair* Stairways are safe with no rotting,deteriorating,or loose parts. J*Okay ❑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 ❑Needs Repair* . The electrical panel is covered and protected from tampering. okay ❑Needs Repair* The gas fuel connection is as approved and safe. eeokay ❑Needs Re air There are no insect or rodent infestations. ❑NeedskRe air* The sewage system is functioning,with no surfacing wastewater or backup. ay ❑Needs kRe air" *Needs Repair:Pleasespecify date repairs to be completed.Any Building Permits required for repairs must be obtained and finaled. I certify that I have inspected the above noted unit and that the information provided is true and correct to the best of my knowledge. SIGNED: Z 1 ilp I Z(-1 DATE TITLE 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com