Cpdpsc 138 Form PDF Details

The CPDPSC 138 form is a document used by the California Department of Public Health to track childhood lead poisoning. The form is used to record data on each child diagnosed with lead poisoning, including information on the child's blood lead level and interventions administered. The CPDPSC 138 form must be completed by healthcare professionals who diagnose a child with lead poisoning. Completion of the form is required in order to receive reimbursement for interventions administered to the child. The CPDPSC 138 form is an important tool for tracking childhood lead poisoning and ensuring that children receive appropriate interventions. Healthcare professionals who diagnose a child with lead poisoning should complete the form and submit it to the California Department of Public Health.

QuestionAnswer
Form NameCpdpsc 138 Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesCPDPSC-138, UO, ca glendale zoning use certificate, s certificate pzuc template

Form Preview Example

Business Address___________________________________________________________________________________________________PZUC No.______________________________________

City of Glendale, Building & Safety

633 E. Broadway, Rm. 101 Glendale, CA 91206 (818) 548-3200 PZUC No.

APPLICATION FOR ZONING USE CERTIFICATE

Instructions: Please answer the following questions as completely and legibly as possible.Please provide a copy of the lease/rental agreement which shows the square footage being leased. Also provide a dimensioned drawing if lease does not show square footage. Please draw a seating plan on the back of the application if the use is for a restaurant, delicatessen, church, classroom or theater.

1.Business Address ( Include Suite No., City and Zip Code):

2.Business Name:

3.Describe in detail the business activities

4.

Applicant's Title?

Owner

President

Officer or CEO

 

 

 

 

 

Business Owner's Name:

 

 

 

 

 

 

 

 

 

 

Mailing Address

 

 

 

 

 

 

 

 

 

 

 

Phone No.

 

 

Fax No. / E-Mail

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5.

Property Owner's Name:

 

 

 

 

 

 

 

 

 

 

Address:

 

 

 

 

 

 

Phone No.:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6.

Existing Building Use:

Gen. Office

Retail

Medical Office

Manufacturing

Wholesale/Distribution

 

 

 

 

Warehouse

Eating Establishment

Other

 

 

 

 

 

 

 

 

 

7.

Proposed Building Use:

Gen. Office

Retail

Medical Office

Manufacturing

Wholesale/Distribution

 

 

 

 

Warehouse

Eating Establishment**

Other

 

 

 

 

 

 

 

 

 

 

8.

Please fill in the following:

 

 

**Draw seating plan on back of application

 

 

Floor Area for Occupancy ( Square Feet ):

 

 

New Business:

 

Yes

No

 

No. of Workers on site:

 

 

First Time Business in Glendale:

 

Yes

No

 

No. of Seats For Patrons:

 

 

Outdoor Storage

 

Yes

No

9.

Are You Sharing Space ( Subleasing )?

Yes

No

Alcoholic Beverage Sales:

 

Yes

No

 

If Yes, From Whom?

 

 

 

If Yes to Alcoholic Beverage Sales:

*

Existing *

Proposed

 

Primary Lessee's UO / PZUC No.

 

 

 

*Attach Copy of Current ABC State License

 

I DECLARE UNDER PENALTY FO PERJURY, THAT THE INFORMATION PROVIDED HEREIN IS TRUE AND CORRECT. I FURTHER ACKNOWLEDGE THE ISSUANCE OF THIS CERTIFICATE DOES NOT RELIEVE ME FROM LEGAL OBLIGATION TO OBTAIN ANY AND ALL NECESSARY PERMITS AND/OR COMPLYING WITH OTHER APPLICABLE LOCAL, STATE, AND FEDERAL REGULATIONS AS MAY APPLY TO THE USE AND /OR BUSINESS

Signature

 

ID/Driver's Lic.:

 

Date:

Signature must be of the applicant listed on item no. 4. If a new Zoning Use Certificate has not been obtained within six months after the application fee is paid, a new application and respective fees shall be collected. Upon written request from the applicant, the Community Planing Director may extend the period of the certificate application.

FOR STAFF USE ONLY ( DO NOT WRITE BELOW THIS LINE)

Accepted By

Date

Receipt No.

Fee

Zoning Designation

 

SIC(Proposed)

Section Sheet

 

 

 

 

 

 

 

 

Staff Comments, Conditions, Restrictions

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Zoning Case Number(s)

 

 

Specify Type of Eating Establishment

 

 

 

 

 

 

 

 

 

OK to Submit By:

 

 

 

Inspection Requiered?

 

 

 

 

 

 

 

 

 

Yes

 

 

 

 

 

 

 

No

 

 

 

 

 

 

 

 

Verified Address with lease

Verified Square Footage with Lease

Denial Letter

OK to Issue By:

 

 

 

 

 

 

 

 

 

CPDPSC-138(03/10)