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i(0 11A, <br /> SA N,J0AQU IN Environmental Health Department <br /> �Jf"catneSS /'ON's heir. <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: MAP DESIGNATION: <br /> HOUSING UNIT INFORMATION <br /> Address or identification number of unit: Date of Inspection: tl 2S <br /> Type of Housing Unit: Single Family Dwelling ❑ Mobile Home ❑ Other: <br /> #Employees in Unit: Date Unit First Built or Installed: <br /> Electrical Power Provided By: Gas Provided by: <br /> HOUSING UNIT INSPECTION <br /> Interior Checklist � Comments <br /> ' <br /> Unit has hot and cold running water. ❑NeAs Repair* <br /> Approved electrical power and gas fuel being supplied to Unit. okay <br /> El Nee Repair* <br /> Heater maintained in functioning and safe manner(No space/portable heaters). I]Nee Okayair* <br /> Doors and windows are accessible/operable to allow for safe exiting, [I NeeOkay <br /> s Repair* <br /> All rooms are clean and sanitary.No insect/rodent infestations present. okay <br /> El Nee* Repair* <br /> All appliances(stove,water heaters,air conditioning units,heaters)are COkay <br /> properlyvented,strapped and are maintained in a safe,workin order, ❑Nees 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). El Need <br /> Needs Repair* <br /> All plumbing in safe,working order(no leaks,properly maintained). Okay <br /> ❑NeeA Repair* <br /> All counters,sinks,toilets,tubs,showers are working and in sanitary condition. Okay <br /> ❑Neeh Repair*.. <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. ❑Ne—e'b6 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. Okay <br /> ❑Nee s Re air' <br /> Stairways are safe with no rotting,deteriorating,or loose parts. kay <br /> El Nee Repair* <br /> Propane tank has barrier protection and"No Smoking"signage. Okay <br /> Ej NeebG Repair* <br /> The trash cans are sufficient in size,have lids and are picked up weekly. Okay <br /> ❑NeecTs Repair*_, <br /> The electrical panel is covered and protected from tampering. Okay <br /> ElNee Re air' <br /> ay <br /> The gas fuel connection is as approved and safe. O R <br /> ❑Ne s Re air* <br /> There are no insect or rodent infestations. kay <br /> ❑N eds Re air* <br /> The sewage system is functioning,with no surfacing wastewater or backup. kay <br /> ElNeeds Repair* <br /> *Needs ai :P lease speci4datg,repairs to be completed.Any Building Permits required for repairs must be obtained and finaled. <br /> I certify_thJA-J1-Ainspeq(edd(e ve noted unit and that the information provided is tr a an correct to the best of my knowledge. <br /> SIGNED: i <br /> ATE TITLE <br /> 1868 E. Hazelton Avenue Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />