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POUIN� NVIRONSAN .JOAQUIN COUNTY <br /> coG <br /> EMENTAL HEALTH DEPARTMENT <br /> RECEIVED <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Y. Telephone: (209) 468-3420 Fax: (209) 464-0138 Web:www.sjgov.org/ehd JUL 3 0 2014 <br /> 14 <br /> DAIRY FARM EMPLOYEE HOUSING NN <br /> ANNUAL PERMIT EXEMPTION SELF-AUDIT HOUSING INSPECTION CHECKLIS RONMENTAL HEALTH <br /> COMPLETE ONE CHECKLIST FOR EACH HOUSING UNIT <br /> FACILITY NAME: D i PR#: <br /> LOCATION: '-L�1 MAP DESIGNATION: <br /> HOUSING UNIT INFORMATION <br /> Address or identification number of unit: 1 ate of Inspection: <br /> Type of Housing Unit: Wsingle Family Dwelling Mobile Home t Duplex❑ Dormitory ❑ Other: <br /> #Employees in Unit: Date Unit First Built or Installed: <br /> Electrical Power Provided By: ° ' Gas Provided by: C, G <br /> HOUSING UNIT INSPECTION <br /> Interior Checklist Comments <br /> Unit has hot and cold running water. kay <br /> ❑ Need Repair* <br /> Approved electrical power and gas fuel being supplied to Unit. kay <br /> ❑ Nee4y Repair* <br /> Heater maintained in functioning and safe manner(No space/portable heaters). E] [ffokay <br /> Need Repair* <br /> Doors and windows are accessible/operable to allow for safe exiting. okay <br /> ❑ Needs Repair* <br /> All rooms are clean and sanitary. No insect/rodent infestations present. okay <br /> ❑ Need epair* <br /> All appliances(stove,water heaters,air conditioning units, heaters)are properly Okay <br /> vented,strapped and are maintained in a safe,working order. ❑ Needs Repair* <br /> All smoke detectors are present and tested to be shown in working order. okay <br /> ElNeeds Repair* <br /> All wiring in safe,working order(no splices,exposed wires, uncovered outlets). UrCkay <br /> ❑ Needs Repair* <br /> All plumbing in safe,working order(no leaks, properly maintained). Elkay <br /> Nee s Repair* <br /> All counters,sinks,toilets,tubs,showers are working and in sanitary condition. okay <br /> ❑ Need a air* <br /> All floors,walls,ceilings are free from holes, are not sagging or buckling, have Okay <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 /> ElNee Re air* <br /> Exterior siding is maintained with no loose plaster,peeling paint,holes,etc. okay <br /> ❑ NeeSjsRepair* <br /> Stairways are safe with no rotting,deteriorating,or loose parts. okay <br /> ❑ Needs Re air* <br /> Propane tank has barrier protection and"No Smoking"signage. LZ1okay <br /> El Needs Repair* <br /> The trash cans are sufficient in size,have lids and are picked up weekly. Okay <br /> ❑ Need Re air* <br /> 21 <br /> The electrical panel is covered and protected from tampering. okay <br /> [INee Repair* <br /> The gas fuel connection is as approved and safe. okay <br /> ElNee Repair* <br /> There are no insect or rodent infestations. okay <br /> ElNee Repair* <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. Building permits required for repairs must be obtained and finaled. <br /> I 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 BY: aA S—I <br /> NAME DATE TITLE <br /> EH 27-XX 4/27/2010 V Dairy Farm Employee Housing <br />