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SAN 10 A Q U I N Environmental Health Department <br /> --COUNTY— <br /> '. <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—". y "�j °e,, PR#: <br /> LOCATION: i a " Cf WQ MAP DESIGNATION: <br /> HOUSING UNIT INFORMATION <br /> Address or identification number of units ' Fj [I' U ..j ate of Inspection: <br /> Type of Housing Unit: ❑Single Family Dwelling �O Mobile Home ❑Other: <br /> #Employees in Unit: j Date Unit First Built or Installed: <br /> Electrical Power Provided By: Gas Provided by: 11 !f <br /> HOUSING UNIT INSPECTION <br /> Interior Checklist Comments <br /> Unit has hot and cold running water. Wkay <br /> ❑Needs Repair* <br /> Approved electrical power and gas fuel being supplied to Unit, Ljqkay <br /> ❑Needs Re air' <br /> Heater maintained in functioning and safe manner(No space/portable heaters). WOkay <br /> ❑Needs Re air* <br /> Doors and windows are accessible/operable to allow for safe exiting. key <br /> ❑Needs Repair* <br /> All rooms are clean and sanitary,No insect/rodent infestations present. P kay <br /> All appliances(stove,water heaters,air conditioning units,heaters)are ❑Needs <br /> Repair* <br /> properly vented,strapped and are maintained in a safe,workingorder. ❑NQl0 Repair* <br /> All smoke and carbon monoxide detectors are present and tested to be shownkay <br /> in workingorder, [I N eds Repair* <br /> All wiring in safe,working order(no splices,exposed wires,uncovered outlets). �Akay <br /> El Jed.- Re air' <br /> All plumbing in safe,working order(no leaks,properly maintained). I Dkey <br /> ❑Needs Re air* <br /> All counters,sinks,toilets,tubs,showers are working and In sanitary condition. Okay <br /> All floors,walls,ceilings are free from holes,are not sagging or buckling,have ❑ <br /> K14-4.D--- <br /> e air' <br /> no water leaks and are clean and in good condition. ❑N ds Y <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. C30ka <br /> Y <br /> ❑Needs Re air" <br /> Stairways are safe with no rotting,deteriorating,or loose parts. Okay <br /> 11N eds Re air' <br /> Propane tank has barrier protection and"No Smoking'signage. Okay <br /> ❑N eds Re air' <br /> The trash cans are sufficient in size,have lids and are picked up weekly. kay <br /> —LLNeeds Re air*. <br /> The electrical panel is covered and protected from tampering. Q kay <br /> Ne ds Re air* <br /> The gas fuel connection is as approved and safe. L rOkay - <br /> -ELNEfeds Re air* <br /> There are no Insect or rodent Infestations. TNds <br /> y <br /> e air* <br /> The sewage system Is functioning,with no surfacing wastewater or backup, yair" <br /> *Needs Re air:Pleasespecify date repairs to be com leted.Any Building Permits required for repairs must be obtained and naiad. <br /> I certify that i have Inspected the above noted unit and that the information provided Is true an correct to the best of my knowledge. <br /> SIGNED: ` f C '' <br /> DATE (✓ TIT <br /> 1868 E. Hazelton Avenue Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />