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SAN J O A Q U I N Environmental Health Department <br /> _ =�tticss yrows , <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: C 1 �� `��d PR#: <br /> eC DESIGNATION:f iJ ► t <br /> HOUSING UNIT INFORMATION <br /> Address or identification number of unit: 3 �,, {yv��rrre QA Date of Inspection: <br /> Type of Housing Unit: ❑ Single Family Dwelling ZMobi e Home ❑ Other: <br /> #Employees in Unit: _ Date Unit First Built or Installed: <br /> Electrical Power Provided By: P L Gas Provided by: <br /> OUSIN_G_UNIT INSPECTION <br /> Interior Checklist Comments <br /> Unit has hot and cold running water. kay <br /> ❑ Needs R' epair' <br /> Approved electrical power and gas fuel being supplied to Unit. kay <br /> ❑ Need5,Repair* <br /> Heater maintained in functioning and safe manner(No space/portable Okay <br /> heaters). ❑ Needs Repair* <br /> Doors and windows are accessible/operable to allow for safe exiting. kay <br /> ❑ Need Repair* <br /> All rooms are clean and sanitary.No insect/rodent infestations present. Okay <br /> El Needs Repair* <br /> All appliances(stove,water heaters,air conditioning units,heaters)are kay <br /> properly vented,strapped and are maintained in a safe,working order. ❑ Need1p,Repair` <br /> All smoke and carbon monoxide detectors are present and tested to be shown Efokay <br /> in working order. ❑ Need Repair* <br /> All wiring in safe,working order(no splices,exposed wires,uncovered outlets). kay <br /> ❑ Need2 Repair <br /> All plumbing in safe,working order(no leaks,properly maintained). G20kay <br /> ❑ Needs Repair <br /> All counters,sinks,toilets,tubs,showers are working and in sanitary condition. y <br /> ElNee Re air* <br /> All floors,walls,ceilings are free from holes,are not sagging or buckling,have 11OKay <br /> no water leaks and are clean and in good condition. ❑ Needs Repair* <br /> Exterior Checklist Comments <br /> Roof is properly maintained with no holes,loose shingles,leaks,etc. Okay <br /> ❑ Need a air* <br /> Exterior siding is maintained with no loose plaster,peeling paint,holes,etc. kay <br /> ElNeed —epair" <br /> Stairways are safe with no rotting,deteriorating,or loose parts. kay <br /> ❑ Nee a air* <br /> Propane tank has barrier protection and"No Smoking"signage. Effokay <br /> ❑ Need a air* <br /> 2i5 <br /> The trash cans are sufficient in size,have lids and are picked up weekly. kay <br /> ❑ Needs,Repair* <br /> The electrical panel is covered and protected from tampering. y <br /> _ ❑ Nee Re air' _ <br /> The gas fuel connection is as approved and safe. ffjOkay <br /> _ <br /> 0 Nee0s Repair* <br /> There are no insect or rodent infestations. Ok y <br /> ❑ Nee Re air* <br /> The sewage systems functioning,with no surfacing wastewater or backup. EffOkay <br /> ❑ Needs Repair" <br /> *Needs Repair. Please specify date repairs to be completed.Any Building Permits required for repairs must be obtained and finaled. <br /> I certify that I have in p cted the above noted unit and that the information provided is true and correct to the best of my knowledge. <br /> SIGNED <br /> BY: _ -�(:)<,c—_ � <br /> NAME ATE TITLE <br /> 1866 EL Hazel o A nue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />