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/'o�C1U1N <br /> ` c°G� SANAOAQUIN Environmental Health Department <br /> —COUNTY <br /> Greatness grows Fere. <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: `VV �, MAP DESIGNATION: <br /> HOUSING UNIT INFO ON <br /> Address or identification number of unit: a.1g rec Aj Date of Inspection: <br /> Type of Housing Unit: Single Family Dwelling ❑ Mobile Home ❑ Other: <br /> #Employees in Unit: Date Unit First Built or Installed: <br /> Electrical Power Provided By: Gas Provided by: <br /> HOUSING UNIT INSPECTION <br /> inftfortheckfist Comments <br /> Unit has hot and cold running water. okay <br /> ❑ Needs Repair* <br /> Approved electrical power and gas fuel being supplied to Unit ®Okay <br /> ❑ Needs Repair* <br /> Heater maintained In functioning and safe manner(No space/portable heaters). ®Okay <br /> ❑ Needs Re air* <br /> Doors and windows are accessible/operable to allow for safe exiting. E]Needs Ry <br /> air* <br /> All rooms are dean and sanitary.No insect/rodent infestations present. ®Okay <br /> ❑ Needs Repair* <br /> All appliances(stove,water heaters,air conditioning units,heaters)are )_$Okay <br /> property vented and are maintained in a safe,working order. ❑Needs Repair* <br /> All smoke and carbon monoxide detectors are present and tested to be shown [$Okay <br /> in working order. ❑Needs Repair* <br /> All wiring in safe,working order(no splices,exposed wires,uncovered outlets). ffrOkay <br /> ❑ Needs Repair* <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. eeOkay <br /> ❑Needs Repair* <br /> All floors,walls,ceilings are free from holes,are not sagging or buckling,have [9Okay <br /> no water leaks and are dean and in good condition. ❑Needs Repair* <br /> Exterior Checkfist Comments <br /> Roof is properly maintained with no holes,loose shingles,leaks,etc. ®Okay <br /> ❑Needs Repair* <br /> Exterior siding is maintained wifli po"plasK peeling paint,holes,etc. okay <br /> E:]Needs Repair* <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. [ROkay <br /> ❑Needs Repair* <br /> The trash cans are sufficient in size,have lids and are picked up weekly. ®Okay <br /> ❑Needs Repair* . <br /> The electrical panel is covered and protected from tampering. Okay <br /> ❑Needs Repair* <br /> [ROThe gas fuel connection Is as approved and safe. Needs <br /> Re air <br /> There are no insect or rodent Infestations. Okay <br /> ElNeeds Repair* <br /> The sewage system is functioning,with no surfacing wastewater or backup. [Okay <br /> ❑Needs Repair* <br /> *Needs Re air.Please specify date repairs to be completed.Any uilding Permits required for repairs must be obtained and finaled. <br /> I certify that 1 have inspected the above noted unit and that the information provided is true and correct to the best of my knowiedge. <br /> SIGNED: —1.L W.'4/ <br /> DATE TmF <br /> 1868 E. Hazelton Avenue I Stockton, Califomia 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />