Annual Comprehensive Facility Inspection

Size: px
Start display at page:

Download "Annual Comprehensive Facility Inspection"

Transcription

1 Office of: Lake County Schools - District Offices 1 West urleigh lvd. Tavares, District Inspector: Inspector #: Lake County Public Safety PO ox 78 Suite 411 Tavares, 778 Joey Graham Local Municipal Inspection uthority: nnual Comprehensive Facility Inspection 1-16 FISH #: ddress: 1 Round Lake Rd. Inspection : 11/9/1 Mt. Dora, 77 Scheduled Reinspection : /7/16 1//1 ctual Reinspection : Print : District: Lake County Facility : K (Elementary) Legend: : 1 = Serious = High = Moderate 4 = Low = Minimal : = Fire Safety = Casualty Safety and Sanitation s from Code: 69-8 = Fire Safety Standards and Requirements for Educational and ncillary Facilities and Plants (F..C.) SREF = Requirements for Educational Facilities (9) FP = ational Fire Protection ssociation iency and Corrective ction Planned and Schedule: O = Operation of Plant -- School Responsibility to complete within 7 days of receipt of inspection report M = Maintenance of Plant -- 9 days to complete after Inspection C = Capital Outlay -- June of fiscal year or becomes part of Plan of Correction = Correction verified by a certified inspector : Y = Yes = o Fire Exit Drill Requirements: FP (1): t least one fire exit drill shall be conducted every month the facility is in session. FP (): One additional fire exit drill shall be required within the first days of operation. Certifications of Compliance with Florida Statutes: District HS complied with section 11.1()(d) and 11. of Florida Statutes regarding corrective action plans and relocatable inspections. Local uthority HS complied with section 11.1()(c) of Florida Statutes regarding plan of action and schedule for correction of each fire safety deficiency Required Exit Drills d as of this inspection date. Signatures: Signature of Facility dministrator cknowledging wareness of Discovered iencies: Signature of Facility dministrator Verifying Required Exit Drills d (if applicable): : : Signature of School District Inspector Reporting iencies: Signature of Local Municipal Inspection uthority Inspector Reporting iencies (if applicable): : :

2 Inspected: 11/9/1 nnual Comprehensive Facility Inspection 1-16 ldg ldg br iency Description and Corrective ction Required Inspector's otes, if any. Location of iency, if specified. 64E-1.4(7)(b) Repair drinking fountain. Repair Water Fountain 1 Pavilion FP Fire extinguisher must be readily accessible and visible at all times. Remove items blocking fire extinguisher. Y ook Storage FP Fire Extinguishers requires maintenance. Fire extinguisher certification tag is out of date. 1 Mechanical FP Fire Extinguishers requires maintenance. Fire extinguisher tag is out of date. 1 Records 64E-1.4(4)(C) Replace burned out bulb(s). Replace bad light bulbs. 1 Y Men s Restroom 64E-1.4(4)(C) Replace burned out bulb(s). Replace bad light bulbs. 1 Y Women s Restroom FP C Replace water damaged ceiling tiles. Replace stained x ceiling tile and check for leaks. 1 Y Page 1 of 1

3 Inspected: 11/9/1 nnual Comprehensive Facility Inspection 1-16 ldg ldg br iency Description and Corrective ction Required Inspector's otes, if any. Location of iency, if specified. 64E-11.6() C Clean microwave. 1 Y FP Remove decorations hanging from ceiling. Remove decorations from ceiling. 1 Y FP Window curtains must have a label or certificate verifying flame retardant properties meeting FP 71. Treat fabric materials with a fire retardant spray and attach certification tag. Y FP Window curtains must have a label or certificate verifying flame retardant properties meeting FP 71. Treat fabric materials with a fire retardant spray and attach certification tag. Y FP portable C extinguisher needs to be installed. Install C fire extinguisher. Mezzanine FP Window curtains must have a label or certificate verifying flame retardant properties meeting FP 71. Treat fabric on wall boards with a fire retardant spray and attach certification tag. Y 64E-11.6() 1 Clean Microwave 1 Y Page of 1

4 Inspected: 11/9/1 nnual Comprehensive Facility Inspection 1-16 ldg ldg br iency Description and Corrective ction Required Inspector's otes, if any. Location of iency, if specified. 64E-1.4()(d) F Clean a/c grille. Clean C return grill. 9 Y Storage 64E-11.6() Clean microwave. 1 Y FP Remove decorations hanging from ceiling. Remove decorations ( balloons ) from ceiling. 1 Y 64E-1.4()(b) Poor storage practices or excess material create fire or health hazard. Store materials orderly and create isle space. 111 Y Storage 64E-1.4()(b) 9 Poor storage practices or excess material create fire or health hazard. Remove items stored on top of light fixture. 111 Y Men s Restroom FP Repair latching device on fire rated door. Repair door latch. FP 7E Replace missing J box cover. Replace J - box cover. 89 Mezzanine ( look up as you enter double doors ) Page of 1

5 Inspected: 11/9/1 nnual Comprehensive Facility Inspection 1-16 ldg ldg br iency Description and Corrective ction Required Inspector's otes, if any. Location of iency, if specified. FP (c) 4 4C 4 Repair the broken electrical outlet. Replace electrical outlet. 8 Stage near storage room door. FP D 4 Fire Extinguishers requires maintenance. Fire extinguisher certification tag is not up to date. 1 Storage FP Replace water damaged ceiling tiles. Replace 1 stained x ceiling tile and check for leaks. 1 Cafeteria West Side FP D Replace water damaged ceiling tiles. Replace stained x ceiling tiles and check for leaks. OTE: 1 tile has a heat detector. 1 Y Storage 64E-11.6() 1E Clean Microwave 1 Y 64E-1.4()(b) Poor storage practices or excess material create fire or health hazard. Store materials orderly and create isle space. 111 Y Storage 64E-11.6() 4C Clean microwave. 1 Y Page 4 of 1

6 Inspected: 11/9/1 nnual Comprehensive Facility Inspection 1-16 ldg ldg br iency Description and Corrective ction Required Inspector's otes, if any. Location of iency, if specified. FP Remove non-approved residential grade furniture/floor coverings or treat with flame retardant + label it. Remove tent. 1 Y 64E-1.4()(b) 9 Poor storage practices or excess material create fire or health hazard. Store materials orderly and create isle space. 111 Y PE Storage FP Window curtains must have a label or certificate verifying flame retardant properties meeting FP 71. Re- treat all fabric materials with a fire retardant spray and attach new certification tag. Y FP Install circuit breaker lockout clip on fire alarm breaker. reaker # is marked RED but does not have lockout clip and not labeled in panel. 4 Electrical Panel PPC FP portable C extinguisher needs to be installed. Install C fire extinguishers. Mezzanine 64E-11.6() Clean microwave 1 Y 64E-1.4(4)(C) Replace burned out bulb(s). Replace bad light bulbs. 1 Y Storage Page of 1

7 Inspected: 11/9/1 nnual Comprehensive Facility Inspection 1-16 ldg ldg br iency Description and Corrective ction Required Inspector's otes, if any. Location of iency, if specified. FP Install circuit breaker lockout clip on fire alarm breaker. reaker # 19 is marked RED but does not have a lockout clip and not labeled in panel. 4 Electrical panel PP6 FP Remove bean bag chair(s). Remove non approved bean bag chairs, they do not have a label. 1 Y FP Fire extinguisher must be readily accessible and visible at all times. Remove cabinet blocking fire extinguisher. Y o iency 7 7 o iencies o deficiencies found at time of inspection. VO 11/9/1 Y Outside Storage (9)(u) 8 Mechanical room shall be free of any storage. () Remove trash and wood pallets blocking electrical panel. Mechanical FP Right side door drags on frame. Generator o iency 477 o iencies o deficiencies found at time of inspection. VO 11/9/1 Y Portable Page 6 of 1

8 Inspected: 11/9/1 nnual Comprehensive Facility Inspection 1-16 ldg ldg br iency Description and Corrective ction Required Inspector's otes, if any. Location of iency, if specified. FP Portable Step Side Door (9)(u) 4 Repair/Replace deficient storage shelving. () nchor shelve to wall. OTE: technician will need (6 inch L brackets ) Y Portable East Side Wall 64E-1.4()(b) 18 Poor storage practices or excess material create fire or health hazard. Improve storage practices ( remove some of the paper books ) 111 Portable SREF (9)(e) 176 Repair window. Re caulk around middle window on East Side. 1 Portable East Side middle window SREF (9)(e) 181 Repair window. Re caulk around middle window. 1 Portable ( middle window East Side ) FP (c) 181 Replace a missing/damaged cover plate. Replace electrical outlet plate. 8 Portable ( ear back door ) SREF ()(a)8 18 Trim the tree branches that create access to the roof. Trim oak tree branches growing over portable roof. 1 Portable (South Side ) Page 7 of 1

9 Inspected: 11/9/1 nnual Comprehensive Facility Inspection 1-16 ldg ldg br iency Description and Corrective ction Required Inspector's otes, if any. Location of iency, if specified. FP Portable Ramp Side Door SREF (11)(e) 8 Residential type appliance must be removed. Remove toaster oven. 1 Y Portable FP Y Portable ack Door FP Repair emergency light. Repair emergency light 4 Portable SREF (9)(e) Repair window. Re Caulk around windows. 1 Y Portable ( East Side ) FP Portable Ramp Side Door FP Portable Ramp Side Page 8 of 1

10 Inspected: 11/9/1 nnual Comprehensive Facility Inspection 1-16 ldg ldg br iency Description and Corrective ction Required Inspector's otes, if any. Location of iency, if specified. FP Portable ack Door FP Replace water damaged ceiling tiles. Replace 1 stained x4 ceiling tile and check for leaks. OTE : this tile has an exhaust fan. 1 Y Portable Restroom FP Repair emergency light. Replace emergency light. 4 Portable FP Portable ack Door SREF ()(b)6.c 48 Washout around foundation piers must be stabilized for proper support. Concrete block column is un stable. 1 Portable ( South East Side ) FP Replace water damaged ceiling tiles. Replace 1 stained x4 ceiling tile and check for leaks. OTE: this tile has an exhaust fan 1 Y Portable Restroom FP Repair emergency light. Repair emergency light 4 West Side Page 9 of 1

11 Inspected: 11/9/1 nnual Comprehensive Facility Inspection 1-16 ldg ldg br iency Description and Corrective ction Required Inspector's otes, if any. Location of iency, if specified. umber of Serious Fire Safety s: Total number of Fire Safety, Casualty Safety and Sanitation s: 61 Total umber of lready d and Items: 4 Page 1 of 1

03. FOOD: Unsealed, left in room, dirty lunch. 03. FOOD: Unsealed, left in room, dirty lunch. 03. FOOD: Unsealed, left in room, dirty lunch

03. FOOD: Unsealed, left in room, dirty lunch. 03. FOOD: Unsealed, left in room, dirty lunch. 03. FOOD: Unsealed, left in room, dirty lunch 6/2/2017 10:58:002. AIR FRESHENERS D27 03. FOOD: Unsealed, left in room, dirty lunch 6/2/2017 10:54:0boxes A59 Need contained 03. FOOD: Unsealed, left in room, dirty lunch 6/2/2017 11:00:3boxes D28 03.

More information

3/20/ :45:33 3/20/ :57:02 3/20/ :02:54 3/20/ :28:43

3/20/ :45:33 3/20/ :57:02 3/20/ :02:54 3/20/ :28:43 3/20/2017 11:45:33 01B. TEMPERATURE: Uncomfortable 10 andrews Very hot x 3/29/17 3/29/17 3/20/2017 11:47:16 02. AIR FRESHENERS 115 x 3/29/17 3/29/17 3/20/2017 12:06:35 02. AIR FRESHENERS Five Told to remove

More information

BSES IEQ Walkthrough Summary Spring Room Observations (Responses)

BSES IEQ Walkthrough Summary Spring Room Observations (Responses) 01A. ODOR: Unusual or offensive 55 01B. TEMPERATURE: Uncomfortable Kitchen Bathroom does not smell clean Kitchen was warm but it had not yet been opened for the day. in room, dirty lunch boxes 45 Need

More information

DISASTER PREVENTION & SAFETY CHECKLIST

DISASTER PREVENTION & SAFETY CHECKLIST DISASTER PREVENTION & SAFETY CHECKLIST Note: If an item does not apply, write N/A (not appropriate) in the Remarks column. DO NOT leave any items blank. ELECTRICAL YES NO DATE INSPECTOR REMARKS All necessary

More information

ANNUAL COMPREHENSIVE SAFETY INSPECTION REPORT STATE BOARD OF EDUCATION ADMINISTRATIVE RULE - SREF 2014 & F.A.C. 69A-58 FISCAL YEAR

ANNUAL COMPREHENSIVE SAFETY INSPECTION REPORT STATE BOARD OF EDUCATION ADMINISTRATIVE RULE - SREF 2014 & F.A.C. 69A-58 FISCAL YEAR ANNUAL COMPREHENSIVE SAFETY INSPECTION REPORT STATE BOARD OF EDUCATION ADMINISTRATIVE RULE - SREF 2014 & F.A.C. 69A-58 FISCAL YEAR 2017-2018 College Facility: South Florida State College SCHOOL / FACILITY:

More information

EMMS IEQ Walkthrough Summary Spring Room Observations (Responses)

EMMS IEQ Walkthrough Summary Spring Room Observations (Responses) 01A. ODOR: Unusual or 5/15/2017 9:55:18 offensive 111 Stained floor, metal shelves with chemicals rusty WOID31122 5/15/17 01B. TEMPERATURE: 5/15/2017 9:24:45 Uncomfortable 2 Inconsistent temperature WOID31121

More information

CCES IEQ Walkthrough Summary Spring Room Observations (Responses)

CCES IEQ Walkthrough Summary Spring Room Observations (Responses) 6/5/2017 10:45:07 6/5/2017 10:50:05 6/5/2017 11:01:09 6/5/2017 11:56:25 6/5/2017 10:44:05 6/5/2017 11:08:12 6/5/2017 11:11:14 6/5/2017 11:15:35 6/5/2017 11:16:11 6/5/2017 11:16:38 6/5/2017 11:33:34 6/5/2017

More information

Food needs to be in sealed containers 03. FOOD: Unsealed, left in

Food needs to be in sealed containers 03. FOOD: Unsealed, left in 01A. ODOR: Unusual or 6/14/2017 14:15offensive Boys room Urine smell 01A. ODOR: Unusual or 6/14/2017 15:16offensive Office Odor and poor air flow x 01B. TEMPERATURE: 6/14/2017 13:42Uncomfortable 202 Warm

More information

Office of Residence Life. Director of Residence Life

Office of Residence Life. Director of Residence Life 3341-2-26 Personalizing Your Living Space. Applicability All University units Responsible Unit Policy Administrator Office of Residence Life Director of Residence Life (A) Policy Statement and Purpose

More information

Facilities Management State-Funded and Billable Services

Facilities Management State-Funded and Billable Services Facilities Management State-Funded and Billable Services Facilities Management receives funding to provide maintenance in eligible state-supported areas only, per UCOP guidelines. State-supported areas,

More information

Unit HH Gregg. ± 30,000 SF Width ±26' Lakeland Retail Center. Lease Outline Drawing. Unit HH Gregg. Depth ± 145' HVAC Units & Information

Unit HH Gregg. ± 30,000 SF Width ±26' Lakeland Retail Center. Lease Outline Drawing. Unit HH Gregg. Depth ± 145' HVAC Units & Information Lease Outline Drawing Lakeland Retail Center 4000 US Hwy. 98, Unit HH Gregg, Lakeland, FL 33809 ±26' ±200' Lease Line Unit HH Gregg ±46' Lease Line ±21' Unit HH Gregg ±145' Lease Line ± 30,000 SF Width

More information

Inspection Points Trailers & Fifth Wheels

Inspection Points Trailers & Fifth Wheels Inspection Points Trailers & Fifth Wheels We at RVIS, LLC appreciate your business and look forward to providing you with the professional RV inspection you deserve. So that we may provide you with a thorough

More information

Fraternity, Sorority and Dormitory Buildings R-2 Fire and Life Safety Standards Inspection Form Fire Code of New York State (19 NYCRR Part 1225.

Fraternity, Sorority and Dormitory Buildings R-2 Fire and Life Safety Standards Inspection Form Fire Code of New York State (19 NYCRR Part 1225. Fraternity, Sorority and Dormitory Buildings R-2 Fire and Life Safety Standards Inspection Form Fire Code of New York State (19 NYCRR Part 1225.1) House Name Date Address Inspector(s) No. of Residents

More information

GENERAL GROUNDS. Inspector Name: Inspector Signature:

GENERAL GROUNDS. Inspector Name: Inspector Signature: Inspector Name: Inspector Signature: Date: Concessions and Dining Areas 1 Are all walking surfaces in good condition and free of slip, trip, and fall 2 Are nonslip materials placed where appropriate? 3

More information

Operations Maintenance and Evaluations

Operations Maintenance and Evaluations Operations Maintenance and Evaluations Adequate exterior maintenance of a chapter house should include annual evaluations, using the following guidelines. The roof should be reviewed with regard to years

More information

Certificate of Inspection CHECKLIST

Certificate of Inspection CHECKLIST Neptune Township Code Enforcement 25 Neptune Boulevard Neptune, NJ 07753 732-988-5200 X211 Inspections@neptunetownship.org Rev. 05/23/18 Certificate of Inspection CHECKLIST For Residential & Commercial

More information

SANTA ROSA FIRE DEPARTMENT FIRE PREVENTION BUREAU STANDARD

SANTA ROSA FIRE DEPARTMENT FIRE PREVENTION BUREAU STANDARD July 2017 SANTA ROSA FIRE DEPARTMENT FIRE PREVENTION BUREAU STANDARD SPECIAL EVENT PUBLIC ASSEMBLY PURPOSE This standard is applicable to any public event, exhibit space, booth, festival or any other similar

More information

UPCS GUIDANCE & PROTOCOL CLARIFICATIONS

UPCS GUIDANCE & PROTOCOL CLARIFICATIONS The following guidance and clarifications are provided as part of REACs continuing effort to minimize the variances in the application of the UPCS protocols and definitions. Site: Overgrown Vegetation-

More information

OCFEC Fire Marshal Summary Report

OCFEC Fire Marshal Summary Report OCFEC Fire Marshal Summary Report Fire Marshal report (Correction Notices received on 6/1/2018) OC FAIR & EVENT CENTER Maintenance Restrooms 1. CCR Title 19 Section 3.28 Plans and Specifications : Submit

More information

UNIVERSITY OF RICHMOND HOUSING FIRE SAFETY POLICY

UNIVERSITY OF RICHMOND HOUSING FIRE SAFETY POLICY UNIVERSITY OF RICHMOND HOUSING FIRE SAFETY POLICY SFTY 2 May, 2002 Revised March, 2003 Revised August, 2004 Revised July, 2005 Revised March, 2006 Revised June, 2007 Revised April, 2008 Revised May, 2009

More information

Fire/Life Safety Policy

Fire/Life Safety Policy Fire/Life Safety Policy On Campus Student Housing A. Purpose The University supports and maintains a strong commitment to the safety and health of each student living in On Campus Student Housing. The

More information

School Fire Safety. A Guide for Educators. saskatchewan.ca

School Fire Safety. A Guide for Educators. saskatchewan.ca School Fire Safety A Guide for Educators saskatchewan.ca Table of Contents Fire happens when a source of heat and a material that will burn come together. The amount of flammable and combustible material

More information

REGULATIONS FOR OUTDOOR GATHERINGS AND EVENTS TENTS & MEMBRANE STRUCTURES

REGULATIONS FOR OUTDOOR GATHERINGS AND EVENTS TENTS & MEMBRANE STRUCTURES REGULATIONS FOR OUTDOOR GATHERINGS AND EVENTS TENTS & MEMBRANE STRUCTURES DATE: January 6, 2014 INFORMATION BULLETIN: F-14-002 APPROVED BY: W. Schellhous 2013 California Fire Code (CFC) and Riverside Municipal

More information

Plot # R019A ± 74' ± 74' ± 65' Plot # R019A LEASE OUTLINE DRAWING GROSS LEASABLE AREA ± 4,631 S.F. DEMISING FRONT WIDTH DEPTH ± 13' ± 32' Lease Line

Plot # R019A ± 74' ± 74' ± 65' Plot # R019A LEASE OUTLINE DRAWING GROSS LEASABLE AREA ± 4,631 S.F. DEMISING FRONT WIDTH DEPTH ± 13' ± 32' Lease Line ± 4' ± 13' ± 72' Lease Line ± 6' ± 7' Plot # R019A ± 18' Lease Line Site N o : Site N ame: Lo catio n: Submitted B y: D rawn by D ate: 991 Santee Trolley Square Santee, CA ID Plans 11/10/2016 This drawing

More information

Building Self-Inspection Program

Building Self-Inspection Program Building Self-Inspection Program www.tridentinsurance.net Lines of Business: Property, General Liability, Worker s Compensation, Public Official Liability Risk Control Strategy/Key Issues: Reduce physical

More information

FLOORS & WALKING SURFACES Y N N/A Corrective Actions Are ALL employees wearing approved slip-resistant footwear?

FLOORS & WALKING SURFACES Y N N/A Corrective Actions Are ALL employees wearing approved slip-resistant footwear? SAMPLE RESTAURANT SAFETY INSPECTION CHECKLIST (Worker Injury Prevention) This Restaurant Safety Inspection Checklist is designed to help assist your organization identify and initiate corrective actions

More information

SJLES IEQ Walkthrough Summary Spring Room Observations (Responses)

SJLES IEQ Walkthrough Summary Spring Room Observations (Responses) 01A. ODOR: Unusual or 4/28/2017 9:45:0offensive 19 Musty and dank 29837 5/5/2017 01B. TEMPERATURE: 4/28/2017 10:20: Uncomfortable 31 Etremely hot 03. FOOD: Unsealed, left in room, dirty lunch 4/28/2017

More information

FIRE DEPARTMENT CONDITIONS BELLEVUE FESTIVAL OF THE ARTS Fire Retardant or Flame Retardant Treatment

FIRE DEPARTMENT CONDITIONS BELLEVUE FESTIVAL OF THE ARTS Fire Retardant or Flame Retardant Treatment FIRE DEPARTMENT CONDITIONS BELLEVUE FESTIVAL OF THE ARTS 2016 The Bellevue Fire Department would like to welcome you to this year s Bellevue Arts Museum Arts Fair. In order to ensure a safe and enjoyable

More information

DAMAGE CODES* CODE DAMAGE COST

DAMAGE CODES* CODE DAMAGE COST 2017-2018 DAMAGE CODES* CODE DAMAGE COST # CODE 100 DOORS 100 DOORS 101 DOOR JAMB REPAIR/REPLACEMENT 250 200 KEYS 102 DOOR KNOB SET REPLACEMENT (APTS) 120 300 WINDOWS 103 DOOR KNOB SET REPLACEMENT (RH)

More information

CORRALES INTERNATIONAL SCHOOL TENANT IMPROVEMENT 5500 WILSHIRE AVE NE ALBUQUERQUE, NM 87113

CORRALES INTERNATIONAL SCHOOL TENANT IMPROVEMENT 5500 WILSHIRE AVE NE ALBUQUERQUE, NM 87113 CORRALES INTERNATIONAL SCHOOL TENANT IMPROVEMENT DRAWING INDEX COVER SHEET G-101 FIRST FLOOR CODE ANALYSIS G-102 SECOND FLOOR CODE ANALYSIS G-103 CAFETERIA CODE ANALYSIS D-101 FIRST FLOOR DEMOLITION PLAN

More information

GARDEN GROVE FIRE DEPARTMENT

GARDEN GROVE FIRE DEPARTMENT GARDEN GROVE FIRE DEPARTMENT PRE-INSPECTION CHECKLIST PROGRAM FOR SCHOOLS The Garden Grove Fire Department provides an annual school life safety inspection each year to protect lives and property in the

More information

SCO # 1 & 2 PUNCLH LIST Project Name: VANCLEAVE UPPER ELEMENTARY CLA#: 13003

SCO # 1 & 2 PUNCLH LIST Project Name: VANCLEAVE UPPER ELEMENTARY CLA#: 13003 SCO # 1 & 2 PUNCLH LIST Project Name: VANCLEAVE UPPER ELEMENTARY CLA#: 13003 No. Discipline Sent to Name Item Date Noted Date Resolved How item was resolved SCO # 1Punch listed items were noted below on

More information

MULTI-LEVEL & COVERED BOOTH CONDITIONS

MULTI-LEVEL & COVERED BOOTH CONDITIONS MULTI-LEVEL & COVERED BOOTH CONDITIONS Covered Booth Definition To place something over or upon an exhibit or portion of an exhibit (e.g., roof, ceiling, tenting, lattice, fabric, plastic) to cover the

More information

Resource, Support, Development, Inc. FIRE EVACUATION DRILL REPORT

Resource, Support, Development, Inc. FIRE EVACUATION DRILL REPORT FIRE EVACUATION DRILL REPORT LOCATION OF EVACUATION: Name Address City State DATE OF EVACUATION: Month Day Year PLACE INDIVIDUALS WERE EVACUATED TO: Time IF INDIVIDUALS WERE NOT EVACUATED TO A SAFE AREA

More information

Troy's Home Inspection Services LLC

Troy's Home Inspection Services LLC Cover Page Property Inspection Report 33706 Inspection prepared for: Cord King & Patricia King Real Estate Agent: Jane Freel - RE/MA Date of Inspection: 3/4/2017 Time: 8:30 Age of Home: 2008 Size: 3279

More information

First Aspen Federal Regulation Set: K LSC 2000 Health Existing

First Aspen Federal Regulation Set: K LSC 2000 Health Existing First Aspen Federal Regulation Set: K 01.01 LSC 2000 Health Existing K 0000 Title CFR Type INITIAL COMMENTS Memo K 0011 If the building has a common wall with a nonconforming building, the common wall

More information

Beaufort County Community College. Maintenance and House Keeping Plan

Beaufort County Community College. Maintenance and House Keeping Plan Beaufort County Community College Maintenance and House Keeping Plan Summary: The College s facility management is handled by the Maintenance Department. The Director of Plant and Maintenance Operations

More information

All temporary special events held within the City of Orlando must be approved and inspected by the Orlando Fire Department prior to holding the event.

All temporary special events held within the City of Orlando must be approved and inspected by the Orlando Fire Department prior to holding the event. December 15, 2005 Dear Event Planner: All temporary special events held within the City of Orlando must be approved and inspected by the Orlando Fire Department prior to holding the event. Applications

More information

Axiom Property Inspections

Axiom Property Inspections Cover Page Axiom Property Inspections Property Inspection Report 868 Wally Avenue, Henderson NV, 89178 Inspection prepared for: John Doe Agent: David Lawson - Axiom Inspection Date: 8/12/2010 Time: 2:30

More information

FORM MUST BE SIGNED AND RETURNED FOR VENDOR PARTICIPATION

FORM MUST BE SIGNED AND RETURNED FOR VENDOR PARTICIPATION Fire Prevention Bureau 95 Culver Street, Simcoe, Ontario N3Y 2V5 519-426-4115 Fax: 519-426-4140 Administration Headquarters Norfolk County Fire and Rescue Services Approval Form Vendor Fire Safety Requirements

More information

UNIVERSITY OF RICHMOND HOUSING FIRE SAFETY POLICY

UNIVERSITY OF RICHMOND HOUSING FIRE SAFETY POLICY UNIVERSITY OF RICHMOND HOUSING FIRE SAFETY POLICY SFTY 2 May, 2002 Revised March, 2003 Revised August, 2004 Revised July, 2005 Revised March, 2006 Revised June, 2007 Revised April, 2008 Revised May, 2009

More information

Special attention should be given to new students, to students with special needs and to students enrolled in visiting classes.

Special attention should be given to new students, to students with special needs and to students enrolled in visiting classes. Fire Prevention Administrative Procedure 8.90 Board Governance Policy Cross Reference: 1, 2, 3, 4, 12, 13, 16, 17 Legal Reference: E10-468R, Section 36, Manitoba Fire Code Date Adopted: January, 1983 Date

More information

Township of Upper Providence Office of the Fire Marshal

Township of Upper Providence Office of the Fire Marshal Township of Upper Providence Office of the Fire Marshal Convention Center Fire Safety Regulations 1286 Black Rock Road P.O. Box 406 Oaks, Pa 19456 9 610N933N9179 JULY 2010 REVISION www.uprovnmontco.org

More information

Green Flag Level Two Survey: Indoor Air Quality Program

Green Flag Level Two Survey: Indoor Air Quality Program Green Flag Level Two Survey: Indoor Air Quality Program You have chosen to work on the Indoor Air Quality (IAQ) program to earn a Green Flag award. Answering these survey questions will take you on a tour

More information

Fire Safety Audit: Part B - Questionnaire (Questionnaire Devised By Mr.R.R.Nair) Yes No x

Fire Safety Audit: Part B - Questionnaire (Questionnaire Devised By Mr.R.R.Nair) Yes No x Fire Safety Audit: Part B - Questionnaire (Questionnaire Devised By Mr.R.R.Nair) Yes No x Name & Address of the Society IDENTIFY PEOPLE AT RISK 01 Have you identified who is at risk? 02 Have you identified

More information

Unit # 1038 ± 900 SF Width ± 15' Depth ± 60'

Unit # 1038 ± 900 SF Width ± 15' Depth ± 60' ±60' Lease Line Lease Outline Drawing Needles Towne Center 1004 E. Broadway St.,, Needles, CA 92363 ± 900 SF Width ± 15' Depth ± 60' Plans produced by: ID Plans 6/16/2017 (813) 657-2545 C 2017 Site map

More information

Sunny Oaks, Inc. Safety & Sanitation Checklist

Sunny Oaks, Inc. Safety & Sanitation Checklist Sunny Oaks, Inc. Safety & Sanitation Checklist Home: Inspector: Date: This inspection is to be done monthly & a response made to each item needing attention. PLEASE CIRLE APPROPRIATE NUMBERT OF LOCATIONS,

More information

JANITORIAL SPECIFICATIONS

JANITORIAL SPECIFICATIONS JANITORIAL SPECIFICATIONS A. Office Areas 1. Empty and wipe outside wastebaskets, replacing liners, if necessary. Remove to appropriate receptacle for disposal. All bins will be returned to their original

More information

Move In Report. Report Information

Move In Report. Report Information 1 of 18 7/29/2009 1:54 PM Move In Report Provided By: WalkThruInspections.Com Report Information Tenants Name(s) John Jones Landlords Name Jill Smith Property Address 5552 SW 27th Place Palm Beach, FL

More information

Camden County Fire Rescue Office of the Fire Marshal 125 N. Gross Road, Kingsland, GA

Camden County Fire Rescue Office of the Fire Marshal 125 N. Gross Road, Kingsland, GA Camden County Fire Rescue Office of the Fire Marshal 125 N. Gross Road, Kingsland, GA 31548 912-510-4302 February 9, 2011 Greetings Camden County Businesses, As always, our department is working vigilantly

More information

IEQ SCHOOL DATA BASE

IEQ SCHOOL DATA BASE LOOK-FORS ROOM/LOCATION COMMENTS ADMIN FACILITIES WORK ORDER NUMBER of POTENTIAL IEQ ASSIGNED COMPLETION 30 DAY REVISIT CLOSED 1. No unusual or offensive odors, gym Too cold on walk through day 15171 12/21/16

More information

CHAPTER 56 EXPLOSIVES AND FIREWORKS SECTION FIREWORKS 1.4G RETAIL STORAGE, DISPLAY, AND SALE

CHAPTER 56 EXPLOSIVES AND FIREWORKS SECTION FIREWORKS 1.4G RETAIL STORAGE, DISPLAY, AND SALE CHAPTER 56 EXPLOSIVES AND FIREWORKS SECTION 5609 is amended, to read as follows, with the entire section being an addition to the Fire Code: SECTION 5609. FIREWORKS 1.4G RETAIL STORAGE, DISPLAY, AND SALE

More information

Structural Guidelines. Food Service Establishments. Retail Food Stores

Structural Guidelines. Food Service Establishments. Retail Food Stores Structural Guidelines for Food Service Establishments and Retail Food Stores Jefferson County Department of Health Food & Lodging Protection Division 1 Before construction or remodeling of a food service

More information

3. Franchisee has successfully completed the STRATUS training program and carries all required certifications and insurance.

3. Franchisee has successfully completed the STRATUS training program and carries all required certifications and insurance. This Agreement, dated June 29, 2018 is made between Stratus Building Solutions ( STRATUS ) and Explore Community School ( CLIENT ). Both STRATUS and CLIENT agree that STRATUS will begin service on July

More information

(Inspector) Scott Ullrich Mailing Address (if Different from Business Location): Address. (FIRE) David Topping City State Zip

(Inspector) Scott Ullrich Mailing Address (if Different from Business Location): Address. (FIRE) David Topping City State Zip CITY OF BARTLESVILLE CHILD CARE HOME BASED BUSINESS LICENSE APPLICATION 401 S. Johnstone, Bartlesville, OK 74003 Phone (918) 338-4233 or (918) 338-4244 INSTRUCTIONS: Please complete application (print

More information

TUFTS FACILITIES SERVICES BASELINE MAINTENANCE VS. CHARGEABLE SERVICES

TUFTS FACILITIES SERVICES BASELINE MAINTENANCE VS. CHARGEABLE SERVICES TUFTS FACILITIES SERVICES BASELINE MAINTENANCE VS. CHARGEABLE SERVICES Below is a list of services delivered by the University s Facilities Services Department. While all of these services are delivered

More information

Building and Grounds Self-Inspection Program

Building and Grounds Self-Inspection Program www.alterisus.com Building and Grounds Self-Inspection Program Each building and its accompanying grounds should be inspected at regular intervals, ideally on a monthly or quarterly basis. In this way,

More information

Wilbur Young Park. Park Land Established: Developed Acres: 15 acres Undeveloped Acres: 25 acres

Wilbur Young Park. Park Land Established: Developed Acres: 15 acres Undeveloped Acres: 25 acres Wilbur Young Park Park Location: 1100 SE Adams Dairy Parkway Park Land Established: 1987 Park Size: 40 acres Developed Acres: 15 acres Undeveloped Acres: 25 acres Park Type: Community Park Amenities: Shelter

More information

IEQ SCHOOL DATA BASE

IEQ SCHOOL DATA BASE LOOK-FORS ROOM/LOCATION COMMENTS ADMIN FACILITIES WORK ORDER NUMBER of POTENTIAL IEQ ASSIGNED COMPLETION 30 DAY REVISIT CLOSED 1. No unusual or offensive odors, or temperature discomfort C26, C09, B11

More information

THE TOWNSHIP OF CRANBURY

THE TOWNSHIP OF CRANBURY THE TOWNSHIP OF CRANBURY FIRE SAFETY BUREAU 23-A North Main Street Cranbury, NJ 08512 PHONE 609-664-3137 FAX 609-395-8861 Dear Cranbury Resident/Real Estate Agent: There have been some changes to the Certificate

More information

Housing and Residence Life Fire Reporting 2015

Housing and Residence Life Fire Reporting 2015 Housing and Residence Life Fire Reporting 2015 Section One: Fire Statistics: Number of fires in 2014 Calendar Year (Spring, Summer, and Fall semesters): 0 Number of fires in 2015 Calendar Year (Spring,

More information

PROPERTY MANAGER S INVENTORY AND CONDITION REPORT

PROPERTY MANAGER S INVENTORY AND CONDITION REPORT PROPERTY MANAGER S INVENTORY AND CONDITION REPORT USE OF THIS FORM BY PERSONS WHO ARE NOT MEMBERS OF THE TEXAS ASSOCIATION OF REALTORS IS NOT AUTHORIZED. Texas Association of REALTORS, Inc. 2004 CONCERNING

More information

FAIRA TRANSPARENCY REPORTS nd Ave S, E-2, SeaTac, WA 98198

FAIRA TRANSPARENCY REPORTS nd Ave S, E-2, SeaTac, WA 98198 608 State St. South Kirkland, WA 98033 www.faira.com hello@faira.com +1.800.571.FAIR FAIRA TRANSPARENCY REPORTS 98198 Thank you for your interest in this Faira Certified home. We have coordinated the efforts

More information

Plant Operations Cleaning and Sanitation Audits.

Plant Operations Cleaning and Sanitation Audits. Plant Operations Cleaning and Sanitation Audits http://plantoperations.dadeschools.net/ DISTRICT-WIDE SCHOOLS Cleaning & Sanitation Audit (4 years) Overall Scores % Fail % Pass 90% 63% 37% 54% 46% 45%

More information

Millard Refrigerated Services Monthly Health and Safety Observations

Millard Refrigerated Services Monthly Health and Safety Observations Millard Refrigerated Services Monthly Health and Safety Observations Completed by: Date: Facility: Page 1 of 6 Y/N State Substandard Conditions and Location Responsibility Dock Area: 1. The overhead dock

More information

HLS Checklist Explanation and Examples

HLS Checklist Explanation and Examples HLS Checklist Explanation and Examples Health/Life Safety requirements became a part of the school code in 1875 after the Great Chicago Fire. Our Lady of Angels Fire (Chicago) in 1958 was another tragic

More information

Kirkstall Brewery Inventory

Kirkstall Brewery Inventory Kirkstall Brewery Inventory Contents: Kirkstall Brewery Single Kirkstall Brewery Premium Single Kirkstall Brewery En-Suite Kirkstall Brewery Premium En-Suite Kirkstall Brewery Premium Plus En-Suite Kirkstall

More information

Safe Schools: A Health and Safety Check

Safe Schools: A Health and Safety Check Name of School: Optional Information Date of Inspection: Vocational Program/Course/Room: Signature of Inspector: General Fire Requirements Self-Inspection Checklist Guidelines: This checklist covers some

More information

dusty. Room shakes and Student restrooms across All vents need cleaning

dusty. Room shakes and Student restrooms across All vents need cleaning Timestamp Observation: 01B. TEMPERATURE: Room Number or Location/Name: Comments for this room: ADMINISTRATION CUSTODIAL 6/1/2017 15:08:34 Uncomfortable 01B. TEMPERATURE: 310 Etremely warm 6/1/2017 15:11:42

More information

FIRE RISK ASSESSMENT Self Assessment

FIRE RISK ASSESSMENT Self Assessment FIRE RISK ASSESSMENT Self Assessment Important! This fire risk assessment form is to be filled in by the responsible person within a business or organisation. As this is a free download for the use of

More information

Home Safety Checklist From Adaptive Remodeling Solutions, LLC Monona, WI

Home Safety Checklist From Adaptive Remodeling Solutions, LLC Monona, WI Home Safety Checklist From Adaptive Remodeling Solutions, LLC 608-234-7440 Monona, WI Are you able to use every part of your home efficiently and safely? Take a good look at the rooms in your home and

More information

Office of Residence Life. Director of Residence Life

Office of Residence Life. Director of Residence Life 3341-2-12 Fire Safety. Applicability All University units Responsible Unit Policy Administrator Office of Residence Life Director of Residence Life (A) Policy Statement and Purpose The purpose is to articulate

More information

The Ultimate Home Maintenance Schedule

The Ultimate Home Maintenance Schedule The Ultimate Home Maintenance Schedule On-Going Quarterly Maintenance Schedule Check interior and exterior faucets for leaks. Clean aerators. Replace washers if Clean with baking soda. Pour water down

More information

Table of Contents CHAPTER 10 ADMINISTRATIVE RULES FOR CERTIFICATION OF CHILD CARE FACILITIES FIRE STANDARDS FOR FAMILY CHILD CARE HOME

Table of Contents CHAPTER 10 ADMINISTRATIVE RULES FOR CERTIFICATION OF CHILD CARE FACILITIES FIRE STANDARDS FOR FAMILY CHILD CARE HOME Table of Contents CHAPTER 10 ADMINISTRATIVE RULES FOR CERTIFICATION OF CHILD CARE FACILITIES FIRE STANDARDS FOR FAMILY CHILD CARE HOME Section No. Subject Page No. 1 Authority and Purpose 10-1 2 Definitions

More information

Watson Home Inspection Services, LLC.

Watson Home Inspection Services, LLC. Cover Page Watson Home Inspection Services, LLC. Property Inspection Report 16466 Olalee Rd, Apple Valley Ca., 92307 Inspection prepared for: Jesse Owens & Zona Owens Agent: Ofir Andrews - Hamilton Landon

More information

SALEM RECREATIONAL VEHICLE SHOW OCTOBER 12, 13, 14, 15, Exhibitor Information Balance of all contracts due before move-in

SALEM RECREATIONAL VEHICLE SHOW OCTOBER 12, 13, 14, 15, Exhibitor Information Balance of all contracts due before move-in SALEM RECREATIONAL VEHICLE SHOW OCTOBER 12, 13, 14, 15, 2017 PRODUCED BY WESTLAKE PROMOTION INC. Exhibitor Information Balance of all contracts due before move-in October 12, 10-7pm October 13, 10-7pm

More information

Housing and Residence Life Fire Reporting

Housing and Residence Life Fire Reporting Section One: Fire Statistics: Housing and Residence Life Fire Reporting 2013-2014 Number of fires in 2008-2009 academic terms (Fall, Spring, and Summer): 02 Number of fires in 2009-2010 academic terms

More information

DUNE ACRES CLUBHOUSE INSTRUCTIONS FOR USE

DUNE ACRES CLUBHOUSE INSTRUCTIONS FOR USE DUNE ACRES CLUBHOUSE INSTRUCTIONS FOR USE NO SMOKING IS PERMITTED IN THE CLUBHOUSE OR ON CLUBHOUSE GROUNDS: The clubhouse building and grounds are smoke free. Please ensure that guests do not smoke on

More information

INSTALLATION GUIDE NZ AU GB IE

INSTALLATION GUIDE NZ AU GB IE COMPANION PRODUCTS Coffee Maker EB60 Steam Oven OS60 Microwave Oven OM60 models INSTALLATION GUIDE NZ AU GB IE CONTENTS Coffee maker 13 1 Safety and warnings 1 2 Parts supplied 2 3 Prior to installation

More information

Please carefully read the below policy regarding Home Partners Standards before completing the renovation checklist!

Please carefully read the below policy regarding Home Partners Standards before completing the renovation checklist! Renovation Checklist Property address: Please carefully read the below policy regarding Home Partners Standards before completing the renovation checklist! Home Partners' Standards for delivering a safe

More information

School Fire Safety Checklist

School Fire Safety Checklist Community Risk Reduction The (SFSC) includes many of the most common fire prevention and life safety issues found in schools. The SFSC is not intended to be an all inclusive list, but rather highlights

More information

Extra Mile Inspection, Inc.

Extra Mile Inspection, Inc. Cover Page Property Inspection Report Inspection prepared for: Jerry and Lynne Richardson Real Estate Agent: Polly Richardson - BHKR Lake Forest Date of Inspection: 3/13/2017 Time: 12 pm Age of Home: built

More information

I. STRUCTURAL SYSTEMS

I. STRUCTURAL SYSTEMS I. STRUCTURAL SYSTEMS A. Foundations Type of Foundation(s): Pier & Beam - Crawlspace Opinion: All exposed areas of the foundation were examined visually. Examination of the foundation was limited to photographs

More information

Unit # H ± 2,000 SF Width ± 25' Depth ± 80'

Unit # H ± 2,000 SF Width ± 25' Depth ± 80' ±80' Lease Line Lease Outline Drawing Sunnymead Plaza 24907 Sunnymead Blvd., Unit # H, Moreno Valley, CA 92553 Unit # H ± 2,000 SF Width ± 25' Depth ± 80' Unit # H Plans produced by: ID Plans 6/13/2017

More information

Cleaning Checklist and Instructions

Cleaning Checklist and Instructions Cleaning Checklist and Instructions The following guideline is provided to assist our residents in cleaning their leased home prior to vacating and to convey our expectations on how the property should

More information

Quarterly Safety/Building Inspection Form

Quarterly Safety/Building Inspection Form Date: Quarter: (Check one) Jan - March, April - June, July - September, Oct - Dec, Campus: Program Name/Building/Room Number: Inspector's Name: 3 4 5 Fire Safety and Emergency Equipment Are all fire extinguishers

More information

SafetyNet FIRE MARSHAL S OFFICE. Food Booth and Vendor Regulations

SafetyNet FIRE MARSHAL S OFFICE. Food Booth and Vendor Regulations UC Davis Health Fire Marshal s Office 4800 2nd Ave, #1200 Sacramento, CA 95817 (916) 734-3036 hs-fireprevention@ucdavis.edu FIRE MARSHAL S OFFICE Food Booth and Vendor Regulations Introduction Vendors

More information

Defiance College Annual Fire Safety Report for 2016

Defiance College Annual Fire Safety Report for 2016 Defiance College Annual Fire Safety Report for 2016 The Campus Fire Safety Right-To-know Act is an amendment to the Higher Education Opportunity Act. This amendment serves to increase campus fire safety

More information

C i t y o f G r o v e r B e a c h ADMINISTRATIVE SERVICES DEPARTMENT

C i t y o f G r o v e r B e a c h ADMINISTRATIVE SERVICES DEPARTMENT C i t y o f G r o v e r B e a c h ADMINISTRATIVE SERVICES DEPARTMENT BUSINESS TAX CERTIFICATE NEW AND RENEWALS Frequently Asked Questions The following are answers to some commonly asked questions regarding

More information

National Property Inspections

National Property Inspections Sunday, February 7, 2016 Inspector Eldon Holliday 901-497-0943 npi@centurytel.net Page 1 of 9 GENERAL INFORMATION GENERAL CONDITIONS AT TIME OF INSPECTION : Yes Property Occupied : Property Faces : þ North

More information

Monday's Date: rented out Friday, Saturday, Sunday til 10 p.m. (high use)

Monday's Date: rented out Friday, Saturday, Sunday til 10 p.m. (high use) 1718 SE 7th open M F 8 a.m. to 5 p.m. Lead's Signature: Monday's Date: rented out, Saturday, Sunday til 10 p.m. (high use) Check off daily or date when complete Main Building W F S X Cobweb Check & Clean

More information

MINNESOTA STATE DEPARTMENT OF PUBLIC SAFETY

MINNESOTA STATE DEPARTMENT OF PUBLIC SAFETY MINNESOTA STATE DEPARTMENT OF PUBLIC SAFETY State Fire Marshal Division 444 Cedar Street, Suite 145, St. Paul, Minnesota 55101-5145 Phone: 651/201-7200 FAX: 651/215-0525 TTY: 651/282/6555 Internet: http://www.fire.state.mn.us

More information

Evaluating a Feast Hall

Evaluating a Feast Hall Evaluating a Feast Hall Contributed by HL Selene Trioros The following is a basic checklist for a site tour for a feast or indoor event. It is by no means complete, but it should give you a good idea of

More information

FIRE INSPECTION GUIDELINES FOR FOSTER GROUP HOME PARENTS Effective June 1, 2002, Update September 2011

FIRE INSPECTION GUIDELINES FOR FOSTER GROUP HOME PARENTS Effective June 1, 2002, Update September 2011 HCFMO Harris County Fire Marshal M.S. Montgomery Fire Marshal FIRE INSPECTION GUIDELINES FOR FOSTER GROUP HOME PARENTS Effective June 1, 2002, Update September 2011 EFFECTIVE JANUARY 1, 2007 These guidelines

More information

STANDARD DETAILS & SPECIFICATIONS Spec No _SI _ Rev. Date 10/20/11

STANDARD DETAILS & SPECIFICATIONS Spec No _SI _ Rev. Date 10/20/11 EST. 1947 STANDARD DETAILS & SPECIFICATIONS Spec No _SI- - - 4_ Rev. Date 10/20/11 SUBJECT: HAUNTED HOUSES/GHOST WALKS Eff. Date 08/23/90 Approved By Page 1 of 6 SCOPE These regulations shall apply to

More information

1710 ANYWHERE DRIVE, MONTGOMERY, AL 36109

1710 ANYWHERE DRIVE, MONTGOMERY, AL 36109 1710 ANYWHERE DRIVE, MONTGOMERY, AL 36109 INFRARED VIEW OF HOME Attention: Mr. John Smith SUBJECT PROPERTY The following inspection of a property located at 1710 Anywhere Drive, Montgomery, AL 36109, was

More information

Unit # E ± 1,200 SF Width ± 20' Depth ± 60'

Unit # E ± 1,200 SF Width ± 20' Depth ± 60' Lease Outline Drawing ±60' Lease Line Sunnymead Plaza 24907 Sunnymead Blvd., Unit # E, Moreno Valley, CA 92553 Unit # E ± 1,200 SF Width ± 20' Depth ± 60' Plans produced by: ID Plans 6/13/2017 (813) 657-2545

More information

Clackamas Fire District #1 Self Inspection Program. Oregon Fire Code (OFC)

Clackamas Fire District #1 Self Inspection Program. Oregon Fire Code (OFC) Clackamas Fire District #1 Self Inspection Program Oregon Fire Code (OFC) Access Access No parking in the fire access lanes at any time. Even if they are not painted red. An unobstructed width of not less

More information

2017 Annual Fire Safety Report

2017 Annual Fire Safety Report 2017 Annual Fire Safety Report King University Security Department Parks Hall 1350 King College Road Bristol, Tennessee 37620 Telephone 423-652-4333 Fax 423-652-6338 Page 1 of 5 Fire Safety The King University

More information

New DATE OF BLDG. PERMIT OR PLAN APPROVAL: SURVEYOR (SIGNATURE) TITLE OFFICE DATE REVIEW AUTHORITY OFFICIAL (SIGNATURE) TITLE OFFICE DATE

New DATE OF BLDG. PERMIT OR PLAN APPROVAL: SURVEYOR (SIGNATURE) TITLE OFFICE DATE REVIEW AUTHORITY OFFICIAL (SIGNATURE) TITLE OFFICE DATE DEPARTMENT OF HEALTH & HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES FIRE SAFETY SURVEY REPORT - AMBULATORY SURGICAL CENTERS Medicare 1. (A) PROVIDER NUMBER Identifying information as shown in

More information