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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 /> FACILITY NAME: <br /> COMPLETE ONE CHECKLIST FOR EACH HOUSING UNIT <br /> .� <br /> LOCATION: PR#: <br /> HOUSING UNIT INFORMATION <br /> " MAP DESIGNATION: <br /> Address or identification number of unit - �7 . 1-1410r, <br /> �' .�� 0.t_) Date of Inspection: <br /> Type of Housing Unit: ❑Single Family Dwelling ''Mobile Home <br /> #Employees in Unit: ` ❑Other: <br /> Date Unit First Built or Installed: <br /> Electrical Power Provided By; ,G , <br /> Gas Provided by: <br /> HOUSING UNIT INSPECTION ' <br /> interior Checklist <br /> Unit has hnI and cold mmning water. Comments <br /> Okay <br /> Approved electrical power and gas fuel being supplied to Unit. Needs Re air' <br /> Oka <br /> Heater maintained in functioning and safe manner(No space/portable heaters). Needs Re air* <br /> t'Okay <br /> Doors and windows are accessible/operable to allow for safe exiting. Nee s.kayay air' <br /> - <br /> El <br /> ds Re <br /> All rooms are clean and sanitary.No Insectfrodent infestations present. Nee Okay air# <br /> All appliances(stove,water heaters,air conditioNng units,heaters)are N eds Re air` <br /> ro erl vented,strapped and are maintained in a safe,wor ea order. Okay <br /> All smoke and carbon monoxide detectors are present and tested to be shown Needs Repair <br /> fn workin order. okay <br /> El <br /> All wiring in safe,working order(no splices,exposed wires,uncovered outlets). Needs Repair" <br /> Okay <br /> All plumbing in safe,working order(no leaks,properly maintained). ❑N kay ds Re atr` <br /> All counters,sinks,toilets,tubs,showers are working and in sanite ds Re air' <br /> ary condition, N <br /> Okay <br /> All floors,walls,ceilings are free from holes,are not sagging or buckling,have EJ N eds Re atr' <br /> no water leaks and are clean and In good condition. gg g Okay <br /> Exterior Checklist ❑Needs Repalr" <br /> Roof is properly maintained with no holes,loose shingles,leaks,etc. Okay Comments <br /> Exterior siding is maintained with no loose plaster,peelin eOka ds a air' <br /> Peeling paint,holes,etc. Y <br /> Stairways are safe with no rotting,deteriorating,or loose parts. N eds kay <br /> air' <br /> ds <br /> Propane tank has barrier protection and'No Smokin 'si na e. N Oka a air' <br /> 9 9 9 y <br /> The trash cans are sufficient In size,have lids and are picked up weekly. N eOkay Re air• <br /> The electrical panel is covered and protected from tampering. ds kay aair• <br /> Oy <br /> The gas fuel connection is as approved and safe. N eds Re air' <br /> Okay <br /> There are no Insect or rodent Infestations. ❑N eds Re air` <br /> Okay <br /> s Re <br /> The sewage system Is functioning,with no surfacing wastewater or backup. N kay air* <br /> "Needs Rape Pleases specify date re airs to be co m leted.An❑Building s Permits required for re airs must be o <br /> I certify that I have Inspected the above noted unit and that the Information pbtained and fina <br /> SIGNED <br /> rovided(s true and correct to the best d n knowledge. <br /> : <br /> - <br /> 13- <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 ( F 209 464- Trr� <br /> 0138 www.sjcehd.com <br />