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SAN J d A Q U I N Environmental Health Department <br /> � ou � 1 y <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: nn l -f PR#: <br /> LOCATION: L`0k COL,. MAP DESIGNATION: <br /> HOUSING UNIT INFORMATION <br /> Address or identification number of unit:,31 5W �, m c� iADate of Inspection: <br /> Type of Housing Unit: ❑ Single Family Dwelling obile Home ❑ Other: <br /> #Employees in Unit: Date Unit First Built or Installed: <br /> Electrical Power Provided By: Vro- Gas Provided by: <br /> OUSING UNIT INSPECTION <br /> Interior Checklist Comments <br /> Unit has hot and cold running water. El Ne 4,6kayeds air' <br /> Approved electrical power and gas fuel being supplied to Unit. ❑eRay <br /> _ ElNeeds Repair* <br /> Heater maintained in functioning and safe manner(No space/portable okay <br /> heaters. _ ❑ Need Repair* <br /> Doors and windows are accessible/operable to allow for safe exiting. — kay <br /> _ ❑ <br /> Needs Repair* <br /> All rooms are clean and sanitary.No insect/rodent infestations present. Okay <br /> ❑ Needs Repair*G <br /> All appliances(stove,water heaters,air conditioning units,heaters)are j6kay <br /> properly vented,strapped and are maintained in a safe,working order. ❑ Nee 5ATepair* <br /> All smoke and carbon monoxide detectors are present and tested to be shown E50kay <br /> in working order. ❑ Needs Repair* <br /> All wiring in safe,working order(no splices,exposed wires,uncovered outlets). El okay <br /> Need2 Repair* <br /> 21 <br /> All plumbing in safe,working order(no leaks,properly maintained). okay <br /> ❑ Need fair* <br /> All counters,sinks,toilets,tubs,showers are working and in sanitary condition. kay <br /> ❑ Needs Repair* <br /> All floors,walls,ceilings are free from holes,are not sagging or buckling,have kay <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. Ej6kay <br /> _ ❑ Needs a air* <br /> Exterior siding is maintained with no loose plaster,peeling paint,holes,etc kay <br /> ❑ N-ne� Repalr" -- - —— — <br /> Stairways are safe with no rotting,deteriorating,or loose parts. Okay <br /> _ ❑ <br /> Ne Repair* <br /> Repair* <br /> Propane tank has barrier protection and"No Smoking"signage. R[v]Ok <br /> ❑ Nee Re air* <br /> The trash cans are sufficient in size,have lids and are picked up weekly. Okay <br /> ❑ Nee Repair* <br /> The electrical panel is covered and protected from tampering. okay <br /> _ ❑ Nee epair* <br /> The gas fuel connection is as approved and safe. Okay <br /> ElNee Repair* _---- <br /> There are no insect or rodent infestations. Okay <br /> El Nee e air* <br /> The sewage system is functioning,with no surfacing wastewater or backup. Okay <br /> ElNeeds Repair' <br /> *Needs Repair: Please specify date repairs to be completed.Any Building Permits required for repairs must be obtained and finaled. <br /> I certify t at I have ins cted the above noted unit and that the information provided is true and correct to the best of my knowledge. <br /> SIGNED <br /> BY: --- clI� -- <br /> NAME DATE TITLE <br /> 86 E. Haze toAvenue I Stockton, California 95205 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />