Lic 610D Emergency Disaster Plan Details

In order to maintain compliance with Form Lic 610D, all Pennsylvania property owners must file an annual declaration of values for their property by March 1st of each year. The form is used to calculate the amount of tax revenue that a municipality will collect from a particular parcel of land. Filing late or failing to file can result in fines and penalties, so it's important to understand the requirements and complete the form correctly. This article provides an overview of Form Lic 610D and instructions on how to complete it.

In the table, there is some good information regarding the form lic 610d. Our tip is that you look at this information before you begin editing the PDF.

QuestionAnswer
Form NameForm Lic 610D
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesemergency disaster plan form, california lic 610d form, disaster adult, lic 610d

Form Preview Example

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

EMERGENCY DISASTER PLAN FOR ADULT DAY PROGRAMS, ADULT RESIDENTIAL FACILITIES, RESIDENTIAL CARE FACILITIES FOR THE CHRONICALLY ILL AND SOCIAL REHABILITATION FACILITIES

INSTRUCTIONS:

Post a copy in a prominent location in facility, near telephone.

Licensee is responsible for updating information as required. Return a copy to the licensing office.

NAME OF FACILITY

ADMINISTRATOR OF FACILITY

FACILITY ADDRESS (NUMBER, STREET,

CITY,

STATE,

ZIP CODE)

TELEPHONE NUMBER

( )

I.ASSIGNMENTS DURING AN EMERGENCY (USE REVERSE SIDE IF ADDITIONAL SPACE IS REQUIRED)

 

NAME(S) OF STAFF

TITLE

ASSIGNMENT

 

1.

 

DIRECT EVACUATION AND PERSON COUNT

 

 

 

 

 

 

2.

 

HANDLE FIRST AID

 

 

 

 

 

 

3.

 

TELEPHONE EMERGENCY NUMBERS

 

 

 

 

 

4.

 

TRANSPORTATION

 

 

 

 

 

5.

 

OTHER (DESCRIBE)

 

6.

II.EMERGENCY NAMES AND TELEPHONE NUMBERS (IN ADDITION TO 9-1-1)

FIRE/PARAMEDICS

POLICE OR SHERIFF

RED CROSS

OFFICE OF EMERGENCY SERVICES

PHYSICIAN(S)

POISON CONTROL

HOSPITAL(S)

AMBULANCE

DENTIST(S)

CRISIS CENTER

LONG TERM OMBUDSMAN

OTHER AGENCY/PERSON

III. FACILITY EXIT LOCATIONS (USING A COPY OF THE FACILITY SKETCH [LIC 999] INDICATE EXITS BY NUMBER)

1.

3.

2.

4.

IV. TEMPORARY RELOCATION SITE(S) (IF AVAILABLE, SUBMIT LETTER OF PERMISSION FROM RENTER/LEASEE/MANAGER/PROPERTY OWNER)

NAME

ADDRESS

TELEPHONE NUMBER

 

 

(

)

NAME

ADDRESS

TELEPHONE NUMBER

 

 

(

)

V.UTILITY SHUT—OFF LOCATIONS (INDICATE LOCATION(S) ON THE FACILITY SKETCH [LIC 999])

ELECTRICITY

WATER

GAS

VI. FIRST AID KIT (LOCATION)

VII. EQUIPMENT

SMOKE DETECTOR LOCATION (IF REQUIRED)

FIRE EXTINGUISHER LOCATION (IF REQUIRED)

TYPE OF FIRE ALARM SOUNDING DEVICE (IF REQUIRED)

LOCATION OF DEVICE

VIII. AFFIRMATION STATEMENT

AS ADMINISTRATOR OF THIS FACILITY, I ASSUME RESPONSIBILITY FOR THIS PLAN FOR PROVIDING EMERGENCY SERVICES AS INDICATED BELOW. I SHALL INSTRUCT ALL CLIENTS/RESIDENTS, AGE AND ABILITIES PERMITTING, ANY STAFF AND/OR HOUSEHOLD MEMBERS AS NEEDED IN THEIR DUTIES AND RESPONSIBILITIES UNDER THIS PLAN.

SIGNATURE

DATE

LIC 610D (10/03) (PUBLIC)

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