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SAN 10AQUIN 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: , 1r'1' PR#: <br /> LOCATION: ell w Ai 61 y (/-2- MAP DESIGNATION: <br /> HOUSING UNIT INFORMATION <br /> Address or identification number of unit: Date of Inspection: /'// - 16, - � <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: 7 <br /> HOUSING UNIT INSPECTION Comments <br /> Interior Checklist <br /> Okay <br /> Unit has hot and cold running water. ❑N90s Repair' <br /> Okay <br /> Approved electrical power and gas fuel being supplied to Unit. ❑N e Re air* <br /> Heater maintained in functioning and safe manner(No space/portablaters). ❑NeedskRe <br /> e heair* <br /> Okay <br /> Doors and windows are accessible/operable to allow for safe exiting. ❑Needs Repair* <br /> [Okay <br /> All rooms are clean and sanitary.No insect/rodent infestations present. ❑Needs Repair' <br /> All appliances(stove,water heaters,air conditioning units,heaters)are NeedsRepay <br /> air* <br /> air* <br /> ro erl vented,strapped and are maintained in a safe,workingorder. ElP <br /> All smoke and carbon monoxide detectors are present and tested to be shown ❑NeedsekRepair' <br /> in workingorder. (Okay <br /> All wiring in safe,working order(no splices,exposed wires,uncovered outlets), ❑Needs Re air' <br /> Okay <br /> All plumbing in safe,working order(no leaks,properly maintained). ❑Needs Repair* <br /> Okay <br /> All counters,sinks,toilets,tubs,showers are working and in sanitary condition. ❑Needs Repair* <br /> All floors,walls,ceilings are free from holes,are not sagging or buckling,have ❑Needs pair* <br /> no water leaks and are clean and in good condition, Comments <br /> Exterior Checklist <br /> Okay <br /> Roof is properly maintained with no holes,loose shingles,leaks,etc. ❑Needs Repair* <br /> ay <br /> Exterior siding is maintained with no loose plaster,peeling paint,holes,etc. ❑NeeeedOskRe air* <br /> POkay <br /> Stairways are safe with no rotting,deteriorating,or loose parts. ❑Needs Re air* <br /> Okay <br /> Propane tank has barrier protection and"No Smoking"signage. ❑Needs Re air* <br /> Okay <br /> The trash cans are sufficient in size,have lids and are picked up weekly. El Needs Re air' <br /> Okay <br /> The electrical panel is covered and protected from tampering. ❑ e <br /> Nds Repair* <br /> 1�90kay <br /> The gas fuel connection is as approved and safe. ❑Needs Repair* <br /> Okay <br /> There are no insect or rodent infestations. ❑Ndeds Repair*_ <br /> kR <br /> ay <br /> The sewage system is functioning,with no surfacing wastewater or backup, ❑N eds Re air* <br /> *Needs Repair:Pleases eci date repairs to be completed.An Buildin Permits required for repairs must be obtained and finaled. <br /> 1 certify that I have inspected the above no 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 952051 T 209 468-34201 F 209 464-0138 1 www.sjcehd.com <br />