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S A W d O A Q U IN Environmental Health Department <br /> —COUNTY— <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:r 5, L MAP DESIGNATION: <br /> HOUSING UNIT INFORMATION <br /> Address or identification number of unit:251125, Date of Inspection: <br /> Type of Housing Unit: Vingle Family Dwelling ❑ Mobile Home ❑Oiher: <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. kay <br /> ❑Need Re air' <br /> Approved electrical power and gas fuel being supplied to Unit. kay <br /> ❑Need Re air' <br /> Heater maintained in functioning and safe manner(No spacelportable heaters). kay <br /> ❑Need a air' <br /> Doors and windows are accessible/operable to allow for safe exiting. L30kay <br /> ❑Needs Re air' <br /> All rooms are clean and sanitary.No insect/rodent infestations present. kay <br /> ❑Needs Repair' <br /> All appliances(stove,water heaters,air conditioning units,heaters)are kay <br /> properlyvented,strapped and are maintained in a safe,working order. ❑Needs Repair' <br /> All smoke and carbon monoxide detectors are present and tested to be shown Mkay <br /> in working order. ❑Need Repair' <br /> All wiring in safe,working order(no splices,exposed wires,uncovered outlets). Okay <br /> ❑Nee Repair* <br /> All plumbing in safe,working order(no leaks,properly maintained). Okay <br /> ❑Neeid5r.Repair` <br /> All counters,sinks,toilets,tubs,showers are working and in sanitary condition. kay <br /> ❑Nee Re air' <br /> All floors,walls,ceilings are free from holes,are not sagging or buckling,have 50kay <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. kay <br /> ElNeed a air' <br /> Exterior siding is maintained with no loose plaster,peeling paint,holes,etc, kay <br /> ❑Need Re air` <br /> Stairways are safe with no rotting,deteriorating,or loose parts, kay <br /> ❑Needs Repair* <br /> Propane tank has barrier protection and'No Smoking'signage. Ejj0kElNeeds a e air• <br /> The trash cans are sufficient in size,have lids and are picked up weekly. y / �G'n e — �It'oe ka <br /> ❑Need a air' . <br /> The electrical panel is covered and protected from tampering. kay <br /> ❑Needs Repair* <br /> The gas fuel connection is as approved and safe. kay <br /> ❑Needs Be pair* <br /> EX <br /> There are no insect or rodent infestations. kay <br /> ElNeeds a air' <br /> The sewage system is functioning,with no surfacing wastewater or backup. kay <br /> ❑Needs Repair* <br /> 'Needs Repair:Pleasespecify date repairs to be completed.Any Building Permits required for repairs must be obtained and finaled. <br /> 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. <br /> 1 �) <br /> SIGNED: ( /7 c� // ��►i�l. �J <br /> DATE TITLE <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />