Form Dhcs 5104 - California Department Of Health Care Services - Page 3

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OUTPATIENT FIRE CLEARANCE*
Fire Authority Name
Address
Telephone Number
(Name of program)
was inspected this date for compliance with local requirements, and is hereby granted a fire
clearance to operate an outpatient alcohol and/or other drug treatment program at:
(Address of program – please include suite numbers if applicable)
Inspector’s name (typed or printed), telephone number
(Signature and rank of inspector granting clearance)
(Inspection date)
*Please do not submit this
Official seal here
sample form as approval.
3
DHCS 5104 (rev. 08/14)

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