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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: S� <br /> LOCATION: PR#: <br /> HOUSING UNIT INFORMATION % MAP DESIGNATION: <br /> Address or identification number of unit: ." U✓ 1 - <br /> '� /`/bate of Inspection: <br /> Type of Housing Ut. &�, ) <br /> nit: ❑Single Family Dwelling Mobile Home <br /> #Employees in Unit: ❑Other: <br /> Unit First Built or Installed: <br /> Date <br /> Electrical Power Provided By; �O�,� , <br /> WOSING�UNIT INSPECTION Gas Provided by: b�rYl <br /> Interior Checklist <br /> Unit has hot and cold running water. Comments <br /> Okay <br /> Approved electrical power and gas fuel being supplied to Unit. 0 Need Ry air' <br /> Oka <br /> Heater maintained in functioning and safe manner(No space/Portable heaters), El <br /> Needs Okay <br /> air~ <br /> Doors and windows are accessible/operable to allow for safe exiting. ❑Needs R air` <br /> ED Re <br /> All rooms are clean and sanitary.No insect/rodent infestations present NeedsOkay <br /> air~ <br /> All appliances(stove,water heaters,air conditioning units,heaters)are Needs ay air~ <br /> ro erl vented strapped and are maintained in a safe,workin order. Okay <br /> All smoke and carbon monoxide detectors are present and tested to be shown Needs Repair' <br /> in workingorder. kay <br /> El <br /> All wiring in safe,working order(no splices,exposed%vires,uncovered outlets), Needs Repair* <br /> Okay <br /> All plumbing in safe,working order(no leaks,properly maintained). E]Needs R'e air~ <br /> All counters,sinks,toilets,tubs,showers are working and in sanitary condition. 0 Need Re air~ <br /> Okay <br /> All floors,walls,ceilings are free from holes,are not sagging or buckling,have Needs Re air~ <br /> no water leaks and are clean and in Dori condition. okay <br /> Exterior Checklist ❑Needs Repair~ <br /> Roof is properly maintained with no holes,loose shingles,leaks,etc. ©okay Comments <br /> Exterior siding Is maintained with no loose plaster,peeling Needs ay air~ <br /> P p � g paint,holes,etc, k7 kay <br /> Stairways are safe with no rotting,deteriorating,or loose parts, 0 Needs Re air* <br /> key <br /> El <br /> Propane tank has barrier protection and'No Smoking"signage. Need Okay ay air~ <br /> The trash cans are sufficient In size,have lids and are picked up weekly, Needkay air~ <br /> The electrical panel is covered and protected from tampering. 0 Needs Re air" <br /> k . <br /> v <br /> Re <br /> The gas fuel connection is as approved and safe. Needs kaayy air~ <br /> ReO <br /> There are no Insect or rodent infestations. Needs kay air' <br /> The sewage system Is functioning,with no surfacing wastewater or backup, Needs air~ <br /> Re air* <br /> "Needs Repair:Pleases ecl date repairs to be com plated.AnYBuildids Perrnfts re wired for re airs must be obtained and final <br /> I certify that I have Inspected the above poted unit and that the Information provided is true and co ect to the best of m knowledge. <br /> SIGNED: }� L� --I <br /> ✓ DAT �.L`. c--f._. ,G�--{�.. <br /> 1868 E. Hazelton Avenue) Stockton, California 95205 1 T 209 468-34201 F 209 464-0138 1 wTILE <br /> wvv.sjcehd.com <br />