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SAN , J OQ MN Environmetal Health Department <br /> Q P <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: O�`' �, `; PR#: <br /> LOCATION: MAP DESIGNATION: <br /> HOUSING UNIT INFORMATION <br /> Address or identification number of unit: f✓D f In pection: f 1, j r <br /> Type of Housing Unit: ❑ Single Family Dwelling Ek0obile Home ❑ Other: <br /> #Employees in Unit: Date Unit First Built or Installed: <br /> Electrical Power Provided By: Gas Provided by: <br /> HOUSING UNIT iNSPEC110N <br /> Interior Checklist Comments <br /> Unit has hot and cold running water. kay <br /> ElNeed Repair* <br /> Approved electrical power and gas fuel being supplied to Unit. EjOkay <br /> ❑ Needs Repair* <br /> Heater maintained in functioning and safe manner(No space/portable Qfdkay <br /> heaters). ❑Need Repair* <br /> Doors and windows are accessible/operable to allow for safe exiting. (Okay <br /> ❑Needs-Re air' <br /> All rooms are clean and sanitary.No insect/rodent infestations present. kay <br /> ❑NeedLs Repair- <br /> All <br /> e air`All appliances(stove,water heaters,air conditioning units,heaters)are Okay <br /> properly vented,strapped and are maintained in a safe,working order. ❑ Need. Repair* <br /> All smoke and carbon monoxide detectors are present and tested to be shown D6kay <br /> in working order. ❑ Need Repair* <br /> All wiring in safe,working order(no splices,exposed wires,uncovered outlets). L30kay <br /> ❑Needs a air* <br /> All plumbing in safe,working order(no leaks,property maintained). kay <br /> ❑Need .,Repair* <br /> All counters,sinks,toilets,tubs,showers are working and in sanitary condition. May❑ Needs a air' <br /> All floors,walls,ceilings are free from holes,are not sagging or buckling,have 06kay <br /> no water leaks and are clean and in good condition. ❑ Needs Repair* <br /> Exterior Checklist EjOComments <br /> Roof is property maintained with no holes,loose shingles,leaks,etc. kay <br /> ❑ Need a air' <br /> Exteror siding is maintained with no loose plaster,peeling paint,Was,etc. ❑ Nee kay <br /> av air' <br /> Stairways are safe with no rotting,deteriorating,or loose parts. Okay <br /> ❑Need,-.,Repair- <br /> Propane <br /> eed Re air*Propane tank has barrier protection and'No Smoking'signage. kay <br /> ❑ Need Re air* <br /> The trash cans are sufficient in size,have lids and are picked up weekly. E�Okay <br /> ❑ Need Re air* <br /> The electrical panel is covered and protected from tampering. El Need[ZOk air* <br /> The gas fuel connection is as approved and safe. LjOkay <br /> ❑ Need Repair* <br /> There are no insect or rodent infestations. y <br /> El <br /> e air* <br /> The sewage system is functioning,with no surfacing wastewater or backup. <br /> ❑ Needs Repair* <br /> *Needs Repair:Please pecify date repairs to be completed.Any Building Permits required for repairs must be obtained and finaled. <br /> I certify tha I have inspe ed the above noted unit and that the information provided is true and correct to the best of my knowledge. <br /> SIGNED 1 i <br /> BY: DATE C TrrLE <br /> NAME 'I V <br /> 18 E. HazeltoV'Avenue Stockton, California 95205 1 T 209468-34201 F 209464-0138 1 www.sjcehd.com <br />