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SAN J 0 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: i_1A e-- PR#: <br /> LOCATION':)_ q_ 0a i"' • t� i ;�,�" <br /> y MAP DESIGNATION: <br /> HOUSING UNIT INFORMATION <br /> Address or identification number of unit:•" i to of Inspection: <br /> Type of Housing Unit: ❑Single Family DwellingTCS Mobile Home ❑Other: <br /> #Employees in Unit: Date Unit First Built or Installed: <br /> Electrical Power Provided By: L Gas Provided by: <br /> HOUSING UNIT INSPECTION <br /> Interior Checklist Comments <br /> Unit has hot and cold running water, .©Okay <br /> ❑Needs Repair* <br /> Approved electrical power and gas fuel being supplied to Unit. U-0 ay <br /> Needs Repair* <br /> Heater maintained in functioning and safe manner(No space/portable heaters). bkay <br /> Eleeds Re air* <br /> Doors and windows are accessible/operable to allow for safe exlting, okay <br /> El Needs Repair* <br /> All rooms are clean and sanitary,No Insect/rodent infestations present, ZOkay <br /> All appliances(stove,water heaters,air conditioning units,heaters eek <br /> are Needs ayRepair* <br /> ro rl vented strapped and are maintained in a safe,workin order. El Needs Repalr' <br /> All smoke and carbon monoxide detectors are present and tested to be shown 120kay <br /> in working order, ❑Needs Repair* <br /> All wiring in safe,working order(no splices,exposed wires,uncovered outlets). Okay <br /> eeds Re air' <br /> All plumbing In safe,working order(no leaks,properly maintained). ®Okay <br /> ❑Needs Re air' <br /> All counters,sinks,toilets,tubs,showers are working and in sanitary condition. POkay <br /> All floors,walls,ceilings are free from holes,are not sagging or buckling,have Needs Needseeds eyRepair' <br /> no water leaks and are clean and in good condition. R <br /> ❑ Repair` <br /> Exterior Checklist <br /> Roof is properly maintained with no holes,loose shingles,leaks,etc. [Okay Comments <br /> ❑Needs Repair* <br /> Exterior siding is maintained with no loose plaster,peeling paint,holes,etc, JelOkay <br /> -- Needs Repair* <br /> Stairways are safe with no rotting,deteriorating,or loose parts. I,10kay <br /> ❑Needs Repair* <br /> Propane tank has barrier protection and"No Smoking'signage. Okay <br /> ❑Needs Re air' <br /> The trash cans are sufficient in size,have lids and are picked up weekly. Cj()kay <br /> ❑Needs Re <br /> The electrical panel is covered and protected from tampering. DOkay <br /> Needs Repair* <br /> The gas fuel connection is as approved and safe. Okay — <br /> eeds Re air* <br /> There are no Insect or rodent Infestations. -00kay <br /> ❑Needs Re air` <br /> The sewage system Is functioning,with no surfacing wastewater or backup. G]0 ay <br /> ❑bleeds Repair' <br /> "Needs Repair.,Pleases eci date re airs to be com leted.An Building Permits required for repairs must be obtained and flnaled. <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: <br /> DATE TITLE r^ <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />