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SA N J OA O U IN 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 I' — :✓t< PR#: <br /> LOCATION: u cz U MAP DESIGNATION: <br /> HOUSING UNIT NFORIVIATION <br /> Address or identification number of unit:,�'12/9 f6?J;AlAn&-'a Date of Inspection: LP <br /> Type of Housing Unit: ingle Family Dwelling ❑ Mobile Home ❑Other: <br /> #Employees in Unit: Date Unit First Built or Installed: <br /> Electrical Power Provided By: — t Gas Provided by: <br /> HOUSING UNIT INSPECTION <br /> Interior Checklist Comments <br /> Unit has hot and cold running water. kay <br /> ❑Need a air' <br /> Approved electrical power and gas fuel being supplied to Unit. [20kay <br /> ❑Needs a air" <br /> Heater maintained in functioning and safe manner(No spacelportable heaters). ay <br /> ❑Needs Repair* <br /> Doors and windows are accessible/operable to allow for safe exiting. EO-kay <br /> ❑Needs Re air' <br /> All rooms are clean and sanitary.No insect/rodent infestations present. kay <br /> ❑Needs Re air' <br /> A!I appliances(stove,water heaters,air conditioning units,heaters)are ay <br /> properly vented strapped and are maintained in a safe,working order. ❑Needs Repair' <br /> All smoke and carbon monoxide detectors are present and tested to be shown E6kay <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). kay <br /> ❑Need Re air" <br /> All counters,sinks,toilets,tubs,showers are working and in sanitary condition. kay <br /> ❑Need5r Repair* <br /> All floors,walls,ceilings are free from holes,are not sagging or buckling,have 90kay <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 /> ❑Needs Repair* <br /> Exterior siding is maintained with no loose plaster,peeling paint,holes,etc. Okay <br /> ElNeeds Repair* <br /> Stairways are safe with no rotting,deteriorating,or loose parts. [YOkay <br /> ❑Needs Repair* <br /> Propane tank has barrier protection and'No Smoking"signage. E40kay <br /> ❑Needs Repair* <br /> The trash cans are sufficient in size,have lids and are picked up weekly. kay <br /> ❑Needs Repair* <br /> The electrical panel is covered and protected from tampering. E38kay <br /> ❑Needs Repair* <br /> The gas fuel connection is as approved and safe. C90kay <br /> ❑Needs Repair* <br /> There are no insect or rodent infestations. eeOkay <br /> El Needs Re air• _ <br /> The sewage system is functioning,with no surfacing wastewater or backup. Ejj&ay <br /> ❑Needs Repair <br /> `Needs Repair:Pleasespecify date repairs to be completed.Any 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 <br /> DATE TITLE <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />