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SAN 10 A 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: G4 PR#: <br /> LOCATION: �/� - r' G L/f�S ,AAAP DESIGNATION: <br /> HOUSING UNIT INFORMATION <br /> Address or identification number of unit: Date of Inspection: <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: 106-2c Gas Provided by: / �7 <br /> HOUSING UNIT INSPECTION Comments <br /> Interior Checklist <br /> Okay <br /> Unit has hot and cold running water. ❑Needs Repair* <br /> [2Okay <br /> Approved electrical power and gas fuel being supplied to Unit. ❑Needs Repair* <br /> [okay <br /> Heater maintained in functioning and safe manner(No space/portable heaters). ❑Needs Re air* <br /> Okay <br /> Doors and windows are accessible/operable to allow for safe exiting. ❑Needs Repair* <br /> 2Okay <br /> All rooms are clean and sanitary.No insectlrodent infestations present. ❑Needs 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. ❑Needs Repair <br /> All smoke and carbon monoxide detectors are present and tested to be shown N eds Repair' <br /> in workingorder. kay <br /> All wiring in safe,working order(no splices,exposed wires,uncovered outlets). 0 Needs Re air <br /> Okay <br /> All plumbing in safe,working order(no leaks,properly maintained). ❑Needs Re air` <br /> Okay <br /> All counters,sinks,toilets,tubs,showers are working and in sanitary condition. Needs Re air* <br /> All floors,walls,ceilings are free from holes,are not sagging or buckling,have Need[SDs Repair* <br /> no water leaks and are clean and in good condition. Comments <br /> Exterior Checklist <br /> kay <br /> Roof is properly maintained with no holes,loose shingles,leaks,etc. ❑Needs Re air• <br /> Okay <br /> Exterior siding is maintained with no loose plaster,peeling paint,holes,etc. p Needs Repair**_ <br /> (Okay <br /> Stairways are safe with no rotting,deteriorating,or loose parts. ❑Needs Re air* <br /> kay <br /> Propane tank has barrier protection and"No Smoking'signage. ❑Needs Re air" <br /> kay <br /> The trash cans are sufficient in size,have lids and are picked up weekly. p N eds Re air* <br /> Okay <br /> The electrical panel is covered and protected from tampering. ❑Needs Re air* <br /> ®Okay <br /> The gas fuel connection is as approved and safe. ❑Needs Re air* <br /> Wk—ay <br /> There are no insect or rodent infestations. ❑Needs Repair* <br /> ®Okay <br /> The sewage system is functioning,with no surfacing wastewater or backup, O Needs Repair* <br /> *Needs Repair:Pleasespecify date repairs to be completed Any Building Permits required for re airs 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: DATE TITLE <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />