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M N <br /> S A N W Q U I N Environmental Health Department <br /> COUNTY— <br /> . <br /> OUNTY <br /> ._,reatness cror s hers. <br /> DAIRY FARM EMPLOYEE HOUSIKG <br /> ANNUAL PERMIT EXEMPTION SELF-AUDIT HOUSING INSPECTION CHECKLIST <br /> COMPLETE ONE CHECKLIS"-.FOR EACH HOUSING UNIT <br /> FACILITY 1-. F, l <br /> _ PR#: <br /> LOCA'i lt:A.' -51e5_w Q MAP DESIGNATION: <br /> ?I+fBI;•^_•°Hr= IF+IT" FORMAT10N <br /> Mdreas c:-ice :tif.zation number of unit: CPAP-A) Date of Inspection: <br /> Type of Ho:!-i:!y I l it: ❑Single Family Dwelling jqMobileHome ❑Other: <br /> #F-.mp!m...r^it r init: Date Unit First Built or Installed- <br /> Electric.a,a-_ i --.v-Med By: Gas Provided by: <br /> IGUSING a At��=4l1!: SECTION <br /> lrateric�r Ci� . irst Comments <br /> Unit has hot and cr!d running water. 00k❑N a air* <br /> f.pproved e!E::.::: ;x:mr and gas fuel being supplied to Unit kay <br /> _ --•---- P_Need a air <br /> (eater maintain;,: ,n rw actioning and safe manner(No space/portable y <br /> heaters). - --- - .-_- ❑Need Repair' <br /> Doors and windows are accessible/operable to allow for safe exiting. <br /> _- -._... ..... ❑Need air* <br /> All rooms are awI sanitary.No inset/rodent infestations present. WOkay <br /> --__-_ [INeed ir* <br /> All appliances u,.ester heaters,air conditioning units,heaters)are 2bkoy <br /> propedy venter;:;,s!r,: .:1 and are maintained in a safe,working order. ❑Needs pair' <br /> All smoke and carvon monoxide detectors are present and tested to be shown Doke <br /> in working er.rl,!] ❑Need epair* <br /> i,II widrg`r. a` 'i^g order(no splices,exposed wires,uncovered outlets). Needs y air* <br /> plumbirr; `.;,-r;;;dc;ng order(no leaks,property maintained). ❑Neeqz ,epair* <br /> All counters,sins s,toilets,tubs,showers are working and in sanitary condition. ❑ ka it <br /> All floors,WAS rwGnos are free from holes,are not sagging or buckling,have 06kay <br /> no water leaks ar,u aro dean and in good condition. ❑Needs Repair' <br /> Exterioe V.-oL;hJist Comments <br /> Roof ism3',•° 'ned with no holes,loose shingles,leaks,at. y <br /> p"�`' ❑ Repair* <br /> Exterior siding ig maintained with no loose plaster,peeling paint,holes,etc. O <br /> ❑Need a air* <br /> Stairways...E s?r7,rlith ro rotting,deteriorating,or loose parts. y <br /> ❑ Re air* <br /> ka <br /> Propane tw.k hay;harrier protection and'No Smoking'signage. <br /> [3Need air- <br /> The trash cai is are 3uf tient in size,have lids and are picked up weekly. ❑ eoair* <br /> ! The electrical panel is covered and protected from tampering. O <br /> ❑ e air* <br /> The gas fus!t:.n- -tion Is as approved and safe. ❑N air• <br /> 'i here are no insect or rodent infestations. <br /> _ ❑ air* <br /> The sewage system is functioning,with no surfacing wastewater or backup, o�y <br /> rHearts Repair* <br /> *Needs Repair.PIej4e gmify date repairs to be completed.Any Building Permits required for repairs must be obtained and ttnaled. <br /> I certify at I have in the above noted unlit and that the btbnnatIon provided Is true and correct to the best of my knowtadpe. <br /> SIGNED <br /> BY: <br /> - NME IDATE True <br /> 1 6 E. HaVon Avenue I Stockton, Califomia 952051 T 209 468-34201 F 209 464-0138 1 www.sjcehd.com <br />