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Environmeal Health De artment <br /> SAN 10AQ�� N p <br /> —COUNTY <br /> — <br /> G <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' Gj LC r S PR#: <br /> LOCATION: ''%d 1 C�\ MAP DESIGNATION: <br /> HOUSING UNIT INFORMATION <br /> Address or identification number of unit: TN- <- Date of Inspection: [ <br /> Type of Housing Unit: Sin le 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 /> Interior ChecklistComments <br /> Okay <br /> Unit has hot and cold running water. F1 Needp Repair* <br /> kay <br /> Approved electrical power and gas fuel being supplied to Unit. ❑ Nee Re air' <br /> Heater maintained in functioning and safe manner(No space/portable Okay <br /> heaters). ❑NeePkay <br /> epair' <br /> Doors and windows are accessible/operable to allow for safe exiting. ❑ Nee Re air' <br /> ky <br /> All rooms are clean and sanitary.No insect/rodent infestations present. ❑ Nee Re air` <br /> All appliances(stove,water heaters,air conditioning units,heaters)are Okay <br /> properly vented,strapped and are maintained in a safe,working order. ❑Need epair` <br /> All smoke and carbon monoxide detectors are present and tested to be shown ka <br /> in workingorder. El epair' <br /> ay <br /> All wiring in safe,working order(no splices,exposed wires,uncovered outlets). ❑Nee s Repair* <br /> Okay <br /> All plumbing in safe,working order(no leaks,properly maintained). ❑Nee Re air' <br /> O y <br /> All counters,sinks,toilets,tubs,showers are working and in sanitary condition. ❑ Nee Re air' <br /> All floors,walls,ceilings are free from holes,are not sagging or buckling,have Okay <br /> no water leaks and are clean and in good condition. ❑Needs pair" <br /> Exterior Checklist Comments <br /> O y <br /> Roof is properly maintained with no holes,loose shingles,leaks,etc. ❑Nee Re air• _, <br /> [ <br /> Exterior siding is maintained with no loesre plaster,peeling paint,holes,etc. O ay <br /> ❑Nee ay air" _ I <br /> Ok y <br /> Stairways are safe with no rotting,deteriorating,or loose parts. ❑Need Re air' <br /> Propane tank has barrier protection and Smoking"signage. ' oy <br /> P P ❑Ne s Re air' <br /> The trash cans are sufficient in size,have lids and are picked up weekly. El Nee <br /> Nee Re air' <br /> The electrical panel is covered and protected from tampering. ❑ NeO y <br /> e sRe air' <br /> Okay <br /> The gas fuel connection is as approved and safe. ❑Nee R air` <br /> O <br /> There are no insect or rodent infestations. ❑Nee Re air* <br /> Okay <br /> The sewage system is functioning,with no surfacing wastewater or backup. ❑Needs Repair' <br /> 'Needs Repair:Please spicify,date repairs to be completed.Any Building Permits required for repairs must be obtained and finaled. <br /> I certify that 1 have inspecte the above noted unit and that the information provided is true and correct to the best of my knowledge. <br /> SIGNED Ci <br /> BY: ATE <br /> NAME--' <br /> TRLE <br /> NAM <br /> 1868 E: Hazelton Av ue Stockton, California 95205 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />