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SAN.,"JOAOUIN>� � 41, Environmental Health Department <br /> COUNTY <br /> Greatness grows here. <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: d PR*: <br /> LOCATION• QJA I Im MAP DESIGNATION- <br /> _1120M UNIT IN .5 <br /> Addren or haengrica Oon number of unit: Data of kWPactlon. ZAg=\�1 <br /> Type of Housing Unit: J'Sinple Family Dwelling ❑Mobile Home ❑Other. <br /> #Employees in Unit _ Data Unit FhV b"A' or Installed: <br /> El9cohocAftif <br /> Power PM~By: Cad'Prodded by: <br /> Comm wrlb <br /> Unit has hot amid cold nnft crater' EPMY <br /> Needs h' <br /> Approved elPr,hmr d Dower and gas fuel bekg suppled b incl <br /> Healer nuintai ed m fmcliiordrrg and safe manner(No spaodportable <br /> Heaters. ❑Needs Repair- <br /> Doors and wkrdcsrs are ameseiblel operable to allow for safe ero'ting. BMW <br /> AI moms are dean and sanitary.No irtst dkodertt WwWorls pwmt. <br /> Al appliances(Wove,wafer healers,air corrdfio ung urine,healers)are KRAW <br /> pmpaq rented, and are rrukMi ued in a s*woddng ander. ❑Need+PAPm*' <br /> AN smoke and carbon morrmrlde ddedom are present and lesled to be shown <br /> in Waft alit. L'i RAstr' <br /> Al wiin9 in safe,worhg oder(no spices, wies,unwvered oud*). Oksy <br /> Al pkrmbitg in safe,woldng order(no leaks,properly maktta ned). ❑ Okay <br /> Nos*RwW <br /> Al counters,sinus,inlets.tube,showers are woddng and in mdbny oarrdttim. !bseA Repai. <br /> Al floors,wak oath gs are flee from Mies,are nd sagging or budd g,have MOksy <br /> no water kldm and are dean and In good oandlon. ❑Needs ReW <br /> Aktifflor ChW k/Mt COIifNDWits <br /> Roof is poly maintained with rto holes,kaase stdm► ,leaks,cm6c <br /> ir' <br /> Ebion siding is mairrWbW with no loose planter,peeling paint,holes,eh 90kayr• <br /> Stairways are safe wdh no raft,delariora ft,or loose pans <br /> Propane tank has barrier protection and'No Smoldng'signage <br /> _a RAPWi <br /> The trash can ane s id ae d In stare„have ids and are pldcod W weetdy. ❑ <br /> !!Mt Pleper <br /> TheekUUpaW19C0WWaWpMWMft0Mt1i1MI1lg. Okay <br /> 13 NeakItApW <br /> The gas fuel connedon Is as appoved and safe. ❑ Ir <br /> There are no freed a modems Mestatiorrs. 70-4 10 NZA W <br /> Rep <br /> The sewage syslam is tundjar ,with no surfacing wadawder or backup. Q Needs r <br /> 'Pleads Reperk:Flom spwgydft MpWm to berm qpmem Perrrdts megWmd for re Are mot be obta W ora Marled. <br /> lcwffy#Wjhmi p ch the Moss noted unit and dWtin Itdonrradom provided is true and correct toftbestai'myluggledw <br /> Soo) <br /> BY: <br /> tncs <br /> 1868 t.pazetbn A ,Cal'nfomta 952051 T 209 468-3420 t F 209 46"138 1 www.sjcehd.com <br /> "y <br />