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SAN J O 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: ,*f . �a l� ' / PR#: <br /> LOCATION: (% �/✓ /� it �t7 IDESIGNATION: <br /> HOUSING UNIT INFORMATION <br /> Address or identification number of unit: Date of Inspection: l v <br /> Type of Housing Unit: ❑ Single Family Dwelling [1 Mobile Home ❑Other: _ <br /> #Employees in Unit: Date Unit First Blailt or Installed: <br /> Electrical Power Provided By: _ Gas Provided by. <br /> HOUSING UNIT INSPECTION Comments <br /> Interior Checklist ®Okay <br /> Unit has hot and cold running water. ❑Needs Re air' <br /> 0Okay <br /> Approved electrical power and gas fuel being supplied to Unit. ❑Needs Re air* <br /> kay <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 Re air' — <br /> JOkay <br /> All rooms are clean and sanitary.No insect/rodent infestations present. ❑Needs Re air' <br /> All appliances(stove,water heaters,air conditioning units,heaters)are Okay <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 ElNeedskay Repair* <br /> in workingorder. Okay <br /> All wiring in safe,working order(no splices,exposed wires,uncovered outlets). ❑Needs Re air' <br /> ,ffOkay <br /> All plumbing in safe,working order(no leaks,properly maintained). p Needs Repair* -- <br /> Wkay <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 notsagging <br /> sagging or buckling,have ❑Ned kRepair` <br /> no water leaks and are clean and in good condition. - Comments <br /> Exterior Checklist n�ikay <br /> Roof is properly maintained with no holes,loose shingles,leaks,etc. (]Needs Repair` -- <br /> — -- Wokay, <br /> Exterior siding is maintained with no loose plaster,peeling paint,holes,etc. ❑Needs Re air` __ ------ ---- <br /> Pokay <br /> Stairways are safe with no rotting,deteriorating,or loose parts. ❑Needs Repair* <br /> Okay <br /> ❑Nee <br /> Propane tank has barrier protection and"No Smoking"signage. ds Repair* - <br /> 70kay <br /> The trash cans are sufficient in size,have lids and are picked up weekly. 4EE1 Needs Re air' — <br /> kay <br /> The electrical panel is covered and protected from tampering. ❑Needs Repair* - <br /> QOkay <br /> The gas fuel connection is as approved and safe. — ❑Nbeds Repair' - <br /> - Okay <br /> There are no insect or rodent infestations. MIT*The sewage system is functioning,with no surfacing wastewater or backup. <br /> "Needs Repair:Pleasespecify date repairs to be completed Any Building Permits required for repairs 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: -- <br /> DATE TITLE <br /> 1868 E. Hazelton Avenue I Stockton, California 952051 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />