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SAN JOANN Environmental Health Department <br /> COU NTY <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: &4C, S PR#: <br /> LOCATION: O\ (��. �� M` yc nV CA MAP DESIGNATION: <br /> HOUSING UNIT INFORMATION <br /> Address or identification number of unit:f 5 W,prrWl (eriVA IJate'of Inspection: — I 0 <br /> Type of Housing Unit: ❑ Single Family Dwelling J2"Mobi e Home ❑ Other: <br /> #Employees in Unit: Date Unit First Built or Installed: <br /> Electrical Power Provided By: Gas Provided by: <br /> OUSING UNIT INSPECTION <br /> Interior Checklist Comments <br /> Unit has hot and cold running water. kay <br /> ❑ Needs Repair* <br /> Approved electrical power and gas fuel being supplied to Unit. ❑okay <br /> ❑ Needs a air' <br /> Heater maintained in functioning and safe manner(No space/portable M6kay <br /> heaters). ❑ Needs Repair" <br /> Doors and windows are accessible/operable to allow for safe exiting. kay <br /> ElNeed a air' <br /> All rooms are clean and sanitary.No insect/rodent infestations present. Okay <br /> ❑ Need a air" <br /> All appliances(stove,water heaters,air conditioning units,heaters)are Okay <br /> properly vented,strapped and are maintained in a safe,working order. ❑ Needs Repair' I <br /> All smoke and carbon monoxide detectors are present and tested to be shown kay <br /> in working order. ❑ Needs Repair" <br /> All wiring in safe,working order(no splices,exposed wires,uncovered outlets). kay <br /> ❑ Need a air' <br /> All plumbing in safe,working order(no leaks,properly maintained). [10kay <br /> ❑ Needs-Repair <br /> All counters,sinks,toilets,tubs,showers are working and in sanitary condition. kay <br /> ❑ Need a air" <br /> All floors,walls,ceilings are free from holes,are not sagging or buckling,have 1310kay <br /> no water leaks and are clean and in good condition. ❑ Needs Repair' <br /> Exterior Checklist Comments <br /> Roof is properly maintained with no holes,loose shingles,leaks,etc. Okay <br /> ❑ Needa Repair* <br /> Exterior siding is maintained with no loose plaster,peeling paint,holes,etc. kay <br /> _ _ ❑ Need Repair" <br /> Stairways are safe with no rotting,deteriorating,or loose parts. "" kay <br /> ❑ Nee Repair* _ <br /> Propane tank has barrier protection and"No Smoking"signage. Okay <br /> ❑ Needs Repair* <br /> The trash cans are sufficient in size,have lids and are picked up weekly. Ok <br /> ❑ Nee Re air" ________ <br /> The electrical panel is covered and protected from tampering. Okay <br /> ❑ Need Re air" <br /> The gas fuel connection is as approved and safe. kay <br /> ❑ Need a air" _ <br /> -.._-------------- <br /> There are no insect or rodent infestations. ❑ Nee kayair" <br /> The sewage system is functioning.with no surfacing wastewater or backup. Okay <br /> ❑ Needs Repair* <br /> 'Needs Repair. Please specify date repairs to be completed.Any 131-1ilding Permits required for repairs must be obtained and finaled. <br /> I certify that I have nspected the above noted unit and that the information provided is true and correct to the best of my knowledge. <br /> SIGNED _ <br /> BY: A - <br /> NAME DATE TITLE <br /> 11VE E Hael orl Avenue Stockton, California 95205 1 T 209 468-3420 F 209 464-0138 1 www.sjcehd.com <br />