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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. ADMINISTRATOR OF FACILITY NUMBER STREET CITY STATE ZIP CODE TELEPHONE NUMBER ASSIGNMENTS DURING AN EMERGENCY USE REVERSE SIDE IF ADDITIONAL SPACE IS REQUIRED TITLE ASSIGNMENT NAME S OF STAFF DIRECT EVACUATION AND PERSON COUNT HANDLE FIRST AID TELEPHONE EMERGENCY NUMBERS TRANSPORTATION OTHER DESCRIBE II. EMERGENCY NAMES ...

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