Lic 610 Form – Fill Out and Use This PDF

The Lic 610 form, also called the "Statement of Controlled Substance Use or Distribution" is used by employers to determine whether a prospective employee has any drug-related convictions within a specific time period.

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Lic 610 Form PDF Details

The Lic 610 form is an important document for businesses in California. This form is used to apply for a license to conduct business in the state. The process of obtaining a business license can be complex, so it is important to understand the requirements and procedures involved. By Famly Law Firm. 2 years ago from FamlyLawFirm's Blog. Licensed by CC BY-NC-ND 4.0) The Lic 610 form is an important document for businesses in California. This form is used to apply for a license to conduct business in the state. The process of obtaining a business license can be complex, so it is important to understand the requirements and procedures involved.

Before you fill out lic 610 form, you will want to know more concerning the type of form you'll work with.

Question	Answer
Form Name	Lic 610 Form
Form Length	1 pages
Fillable?	Yes
Fillable fields	43
Avg. time to fill out	8 min 51 sec
Other names	california emergency form, lic plan care, lic 610, disaster plan child care

12

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

EMERGENCY DISASTER PLAN FOR CHILD CARE CENTERS

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)

POLICE OR SHERIFF

OFFICE OF EMERGENCY SERVICES

RED CROSS

POISON CONTROL

HOSPITAL(S)

OTHER AGENCY/PERSON

CHILD PROTECTIVE SERVICES

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/LEASSOR/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 610 (10/03) (PUBLIC)

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california emergency form spaces to fill in

Enter the essential particulars in ADDRESS, TELEPHONE, NUMBER, TELEPHONE, NUMBER NAME, ADDRESS, WATER, GAS, FIRE, EXTINGUISHER, LOCATION, IF, REQUIRED and LOCATION, OF, DEVICE section.

step 2 to completing california emergency form

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california emergency form DATE, and LICPUBLIC blanks to complete

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