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SAN J OA Q U I N Environmental Health Department <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: PR#: <br /> LOCATION' lu y Ytil j' C'O _ P52AZ MAP DESIGNATION: <br /> HOUSING UNIT INFORMATION <br /> Address or identification number of unit: �j �,, ��yvt feof Inspection: <br /> Type of Housing Unit: Single Family Dwelling ❑ Mobile eorne ❑ Other: <br /> #Employees in Unit: Date Unit First Built or Installed: <br /> Electrical Power Provided By: �-y Gas Provided by: eT <br /> OUSIN_G UNIT_INSPECTION f <br /> _ <br /> Interior Checklist — Comments <br /> Unit has hot and cold running water. 21] kay <br /> i ❑ Needs Re air' <br /> Approved electrical power and gas fuel being supplied to Unit. kay <br /> _ ❑ Need Repair <br /> Heater maintained in functioning and safe manner(No space/portable ff0kay <br /> heaters). ❑ Need2 Repair* <br /> Doors and windows are accessible/operable to allow for safe exiting. okay <br /> [Ell Need Re air* <br /> All rooms are clean and sanitary.No insect/rodent infestations present. kay <br /> _ ❑ Need Repair's <br /> All appliances(stove,water heaters,air conditioning units,heaters)are 215kay <br /> properly vented,strapped and are maintained in a safe,working order. ❑ Ne_ed�Repair' _ <br /> All smoke and carbon monoxide detectors are present and tested to be shown I QOkay <br /> in working order. _ I ❑ Need Repair' I -_ <br /> All wiring in safe,working order(no splices,exposed wires,uncovered outlets). Okay <br /> ❑ Nee Repair* <br /> All plumbing in safe,working order(no leaks,properly maintained). okay <br /> ❑ Nee5Ls Repair <br /> All counters,sinks,toilets,tubs,showers are working and in sanitary condition. Okay <br /> ❑ Need 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 Repair* <br /> Exterior Checklist Z Comments <br /> Roof is properly maintained with no holes,loose shingles,leaks,etc. okay <br /> ElNeed Re air* <br /> Exterior siding is maintained with no loose plaster,peeling paint.holes,etc. Okay <br /> ❑ Neeqs Repair* <br /> Stairways are safe with no rotting,deteriorating,or loose parts. G. Okay <br /> _ ❑ Nea Repair* <br /> Propane tank has barrier protection and"No Smoking"signage. T Okay <br /> _ ❑ Nee Re air* _ <br /> The trash cans are sufficient in size,have lids and are picked up weekly. LffOkay <br /> ElNee Repair_ _ <br /> The electrical panel is covered and protected from tampering. okay <br /> ❑ Nee Repair________ <br /> The gas fuel connection is as approved and safe. Okay <br /> El Nee0s Repair* <br /> There are no insect or rodent infestations. 0 ay <br /> ❑ NeeA Repair <br /> The sewage system is functioning,with no surfacing wastewater or backup. 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 it pected the above noted unit and that the information provided is true and correct to the best of my knowledge. <br /> SIGNED _ <br /> BY: Ll <br /> / NAME DATE TITLE <br /> 1 6 E. Haze t n A enue I Stockton, California 952051 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />