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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: le 7 PR#: <br /> LIZ <br /> LOCATION: �J/ W Ay'n / v� /�` L C MAP DESIGNATION: <br /> HOUSING UNIT INFORMATION <br /> Address or identification number of unit: Date of Inspection: 4,11 <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 Comments <br /> Interior Checklist <br /> (Okay <br /> Unit has hot and cold running water. ❑Needs Repair* <br /> kay <br /> Approved electrical power and gas fuel being supplied to Unit. ❑Needs Repair' <br /> Heater maintained in functioning and safe manner(No space/portable heaters). kayNeeds Repair* <br /> BOkay <br /> Doors and windows are accessible/operable to allow for safe exiting. ❑Needs Re air* <br /> (Okay <br /> All rooms are clean and sanitary.No insect/rodent infestations present. [:1 Needs Repair* <br /> All appliances(stove,water heaters,air conditioning units,heaters)are i�Okay <br /> properly vented,strapped and are maintained in a safe,workingorder. ElNeeds Repair* <br /> All smoke and carbon monoxide detectors are present and tested to be shown Nb dskRepair' <br /> in workingorder. Okay <br /> All wiring in safe,working order(no splices,exposed wires,uncovered outlets). E]Needs Repair* <br /> Okay <br /> All plumbing in safe,working order(no leaks,properly maintained). ❑ eeds Repair* <br /> ,EOkay <br /> All counters,sinks,toilets,tubs,showers are working and in sanitary condition. p Needs Re air* <br /> All floors,walls,ceilings are free from holes,are not sagging or buckling,have ❑Needs Repair* <br /> no water leaks and are clean and in good condition. Comments <br /> Exterior Checklist <br /> aflkay <br /> Roof is properly maintained with no holes,loose shingles,leaks,etc. ❑Needs Re air* <br /> Exterior siding is maintained with no loose plaster,peeling paint,holes,etc. El Needs kRe air* <br /> kay <br /> Stairways are safe with no rotting,deteriorating,or loose parts. ❑Needs Repair* <br /> [,4Okay <br /> Propane tank has barrier protection and"No Smoking"signage. ❑Needs Repair* <br /> `Okay <br /> The trash cans are sufficient in size,have lids and are picked up weekly. [I Needs Repair* <br /> kay <br /> The electrical panel is covered and protected from tampering. ❑Needs Repair* <br /> 23Okay <br /> The gas fuel connection is as approved and safe. ❑Needs Re air* <br /> [40k <br /> ay <br /> are no insect or rodent infestations. ❑Weds Repair* <br /> air* <br /> [50kay <br /> The sewage system is functioning,with no surfacing wastewater or backup. p Needs to air* <br /> *Needs Re air.Please specifv date repairs to be completed.Any Building Permits required for re airs must be obtained and finaled. <br /> 1 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: 1- 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 />