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SAN JOAQUIN Environmental Heal 9#01 <br /> rtment <br /> .r: VEL) <br /> FEB 0 l tali, <br /> DAIRY FARM EMPLOYEE HOUSING EWRORAj�NTAL/I <br /> ANNUAL PERMIT EXEMPTION SELF-AUDIT HOUSING INSPECTION CHECKLIST _r'SER!�C� <br /> COMPLETE ONE CHECKLIST FOR EACH HOUSING UNIT Z <br /> FACILITY NAME: ® PR#: S I S�' 7 <br /> LOCATION: MAP DESIGNATION: <br /> HOUSING UNIT INFORMATION (� <br /> Address or identification numbef of unit: Date of Inspection: <br /> 'Type of Housing Unit: q Single Family Dwelling ❑ Mobile Home ❑ Other: <br /> #Employees in Unit: - - Date Unit First Built or Installed: --_ - <br /> Electrical Power Provided By: C Gas Provided by: <br /> .OUSING UNIT INSPECTION <br /> Interior Checklist _ _ Comment <br /> Unit has hot and cold running water. —Okay - <br /> - El 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 Wokay <br /> heaters. -- ❑ Needs Repair* — - —_ - <br /> Doors and windows are accessible/operable to allow for safe exiting. okay <br /> ❑__Nee s <br /> All rooms are clean and sanitary.No insect/rodent infestations present. Okay <br /> _ ___ ❑ Neeos_Re},air" <br /> All appliances(stove,water heaters,air conditioning units,heaters)are -- Okay I <br /> properly vented,strapped and are maintained in a safe,working order. I ❑ Nee Repair* ----- -__ --- <br /> All smoke and carbon monoxide detectors are present and tested to be shown T Okay <br /> in working order rder —_ ❑ Needs Repair* i — <br /> Ail wiring in safe,working urder(no splices,exposed wires,uncovered outlets). [j)0kay <br /> — —�[I Needs Re air* ---- - - - ---- <br /> All plumbing in safe,working order(no leaks,properly maintained). Okay <br /> I ❑ Nee s Rehr'--- - <br /> y <br /> All counters,sinks:toilets,loos,showers are working and in sanitary condition. i ❑ Nees Repair* <br /> All floors,walls,ceilings are free from holes,are not sagging or buckling,have 90kay <br /> no water leaks and are clean and in good condition. —- ❑ Needs Repair' _ <br /> Exterior Checklist Comments <br /> Roof is properly maintained with no holes,loose shingles,leaks,etc. Okay <br /> El Nee Repair* <br /> Exterior siding is maintained with no loose plaster,peeling paint,holes,etc. Okay <br /> i ❑ Neeca R�air �---___—_ <br /> .. <br /> Stairways are sale with no rotting,oeterlcr:ting,or loose part,. <br /> �s <br /> _❑__fJ_f__� Repair' <br /> [-j _- ------- -- - -- - -- - -._.._.. --o- -.--------- - -- - - --- .._.-------- - - ------ ----- <br /> Propane tank has barrier protection and"No Smoking"signage. OKay <br /> _ ❑ Nee Re air* <br /> The trash cans are sufficient in size,have lids and are picked up weekly. Okay <br /> ElNee s Re air* _ <br /> The electrical panel is covered and protected from tampering. okay <br /> --- - -- ❑ <br /> Needz Repair* --- <br /> The gas fuel connection is as approved and safe Okay <br /> ❑_Neeftrs Repair* <br /> There are no insect or rodent infestations. - 0 <br /> � ❑ Nee Repair* <br /> air* <br /> The sewage system is funct�oning ith no surfacing avasiewater or Cackup — Okay <br /> ❑ Needs Repair* <br /> *Needs Repair: Please specify date repairs to be completed.Any Building Permits required for repairs must be obtained and finaled. <br /> I certify that I have inspected the above noted unit and that the information provided is true and correct to the best of my knowledge. <br /> SIGNED <br /> BY: <br /> NAME DATE TITLE <br /> 18 E. Ha on Avenue I Stockton. California 95205 1 T 209 468-3420 1 F 209 464-0138 1 w vw.sjcehd.com <br />