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SAN J OA Q U I N Environmental Health <br /> 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: x.. <br /> LO(ATION: <br /> I PR#: <br /> HOUSING UNIT INFORMATION ' MAP DESIGNATION: <br /> Address or identification number of unit:�L C{L� �� /)� <br /> Type of HousingUnit: y g Date of Inspection: ,� <br /> ❑Single Famil Dwelling �rMobile Home <br /> #Employees in Unit: 11 Other: <br /> Date Unit First Built or Installed: <br /> Electrical Power Provided By: <br /> HOUSING UNIT NSPECTION Gas Provided by: �; , <br /> Interior Checklist <br /> Unit has hot and cold running water. OkaComments <br /> y <br /> Needs Re air" <br /> Approved electrical power and gas fuel being supplied to Unit, key <br /> Heater maintained in functioning and safe manner(No space/portable heaters). Needs kays Re air. <br /> Doors and windows are accessible/operable to allow for safe exiting. NeeOkay air <br /> Needs Re air* <br /> All rooms are dean and sanitary.No insect/rodent infestations present, key <br /> All appliances(stove,water heaters,air conditioning units,heaters)are Needs Re air* <br /> r erl vented,stra ed and are maintained Ina safe workin order. kay <br /> All smoke and carbon monoxide detectors are present and tested to be shown N eds Repair" <br /> In workingorder. )kay <br /> All wiring in safe,working order(no splices,exposed wires,uncovered outlets), I]Needs Repair* <br /> Okay <br /> Re All plumbing in safe,working order(no leaks,properly maintained), eeds Okay air* <br /> All counters,sinks,toilets,tubs,showers are working and Insanitary condition. Beds Re air° <br /> key <br /> All floors,walls,ceilin s are free from hales are not sag,m or buckling, 11 e s Re air* <br /> no water leaks and a clean and in good condition, g g okay <br /> Exterior Checklist ❑Needs Repair* <br /> Roof is properly maintained with no holes,loose shingles,leaks,etc, Qbkay Comments <br /> Exterior siding is maintained with no loose Plaster,peeling NIa s ay air* <br /> p p g paint,holes,eta Okay <br /> Stairways are safe with no rotting,deteriorating,or loose partska,, Needs y air~ <br /> Propane tank has barrier protection and"No Smoking"signage. Nee key <br /> air* <br /> The trash cans are sufficient in size,have lids and are picked up weekly. Nee key air* <br /> The electrical panel is covered and protected from tampering. Needs Re air` . <br /> Okay <br /> The gas fuel connection is as approved and safe. ❑Needs Re air- <br /> key <br /> There are no insect or rodent infestations. Needs Re air* <br /> key <br /> The sewage system is functioning,with no surfacing wastewater or backup. Needs key <br /> air' <br /> `Needs Repair Pleases ci date re airs to El <br /> Re air* <br /> be Com leted.AnBuildins <br /> I cePermits required for re airs must be obtained and final <br /> rtify that I ave inspected the above noted unit and that the informatio <br /> SIGNED: n provided is true and rrect to the best of m knowledge. <br /> � .- <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 T�T�e <br /> T 209 468-34201 F 209 464-0138 wvuw.sjc IVLE m <br />