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S A N J O A Q U I N Environmental Health Department - COUNTY-0". .�..j GreaIrieSS DAIRY FARM EMPLOYEE HOUSING ANNUAL PERMIT EXEMPTION SELF-AUDIT HOUSING INSPECTION CHECKLIST COMPLETE ONE CHECKLIST FOR EACH HOUSING UNIT FACILITY NAME: f PR#: (� LOCATION: d MAP DESIGNATION: HOUSING UNIT INFORMATION Address or identification number of unit: Date 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: 110, Gas Provided by: e� a.. HOUSING UNIT INSPECTION Interior Checklist Comments Unit has hot and cold running water. kay ❑19ee0s Repair* Approved electrical power and gas fuel being supplied to Unit. Okay ❑ Needs Repair* Heater maintained in functioning and safe manner(No spacelportable heaters). Okay ❑Neeos Repair* Doors and windows are accessible/operable to allow for safe exiting. Okay ❑Nee0 Repair* All rooms are clean and sanitary.No insecilrodent infestations present. kay ❑ Needs Repair* All appliances(stove,water heaters,air conditioning units,heaters)are ZjOkay 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 Z10kay in working order. ❑Needs Repair' All wiring in safe,working order(no splices,exposed wires,uncovered outlets). Okay ❑NeeA 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 Zrokay 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 ❑Nee0s Repair* Exterior siding is maintained with no loose plaster,peeling paint,holes,etc. okay ❑Ne2o Repair* Stairways are safe with no rotting,deteriorating,or loose parts. Okay ❑ Nee a air' 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. j?jOkay ❑Need a air' The electrical panel is covered and protected from tampering. okay ❑Need Repair* The gas fuel connection is as approved and safe. okay ❑Needs Repair* There are no insect or rodent infestations. [30kay ❑Needs Repair* The sewage system is functioning,with no surfacing wastewater or backup, kay ❑Needs Repair* *Needs Repair:Please specify 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: / DATE TfTLE J 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com