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SAN JOAQUIN Environmental Health Department <br /> COU NTY <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: CC, L.�" PR#: <br /> LOCATION: L W. c m C C "tCj Z MAP DESIGNATION: <br /> HOUSING UNIT INFORMATION <br /> Address or identification num er of unit:" - W, ate of Inspection: <br /> Type of Housing Unit: ingle Family Dwelling VIVIobile Morne ❑ Other: <br /> #Employees in Unit: X Date Unit First Built or Installed: <br /> Electrical Power Provided By. Gas Provided by: Y <br /> OUSING UNIT INSPECTION <br /> Interior Checklist Comments <br /> Unit has hot and cold running water. kay <br /> ❑ Need Repair* 1 <br /> Approved electrical power and gas fuel being supplied to Unit. kay <br /> _ ElNeed Repair* <br /> Heater maintained in functioning and safe manner(No space/portable 90kay <br /> heaters). _ ❑ Neecfs Repair* <br /> Doors and windows are accessible/operable to allow for safe exiting. okay <br /> El Nee Repair* _ <br /> All rooms are clean and sanitary.No insect/rodent infestations present. Okay <br /> ❑ <br /> Need5 Repair* <br /> All appliances(stove,water heaters,air conditioning units,heaters)are kay <br /> properly vented,strapped and are maintained in a safe,working order. ❑ Need Repair* <br /> All smoke and carbon monoxide detectors are present and tested to be shown Okay <br /> in working order. ❑ Needs Repair* <br /> All wiring in safe,working order(no splices,exposed wires,uncovered outlets). kay <br /> El NeeRe air* <br /> All plumbing in safe,working order(no leaks,properly maintained). okay <br /> _ _ ❑ Nee Repair <br /> All counters,sinks,toilets,tubs,showers are working and in sanitary condition. Okay <br /> ❑ Need Rep air* <br /> All floors,walls,ceilings are free from holes,are not sagging or buckling,have DOkay <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 /> ❑ Needs Repair* <br /> Exterior siding is maintained with no loose plaster,peeling paint,holes,etc. [ kay <br /> ❑ Nee s Repair* _ <br /> Stairways are safe with no rotting,deteriorating,or loose parts. C Okay <br /> ❑ Needs Repair* <br /> Propane tank has barrier protection and"No Smoking"signage. okay <br /> ❑ Nee s Repair* <br /> The trash cans are sufficient in size,have lids and are picked up weekly. kay <br /> El Nees Repair* <br /> The electrical panel is covered and protected from tampering. okay <br /> ElNee Repair <br /> The gas fuel connection is as approved and safe. Okay <br /> ❑ Neegfs Repair* <br /> There are no insect or rodent infestations. Okay <br /> ____ ❑ Nee 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 ii pected the above noted unit and that the information provided is true and correct to the best of my knowledge. <br /> SIGNED <br /> BY: .- — � --� - - --- - -- - - -F - --- - <br /> NAME--411 <br /> DATE TITLE <br /> 18 8 . Ha elt n Venue I Stockton, California 952051 T 209 468-3420 j F 209 464-0138 1 www.sjcehd.com <br />