Get Lic421 Form

The Lic421 Form is essential for facilities assessed with civil penalties for licensing violations in California. This guide provides a clear, step-by-step approach to help users successfully complete the form online while ensuring compliance with necessary regulations.

Follow the steps to fill out the Lic421 Form efficiently.

1. Click the ‘Get Form’ button to acquire the Lic421 Form and open it in your selected editing tool.
2. Input the facility name at the top of the form to identify the location subject to the civil penalty assessment.
3. Fill in the date of assessment, facility address, city, state, and zip code to ensure accurate location identification.
4. Provide the licensee(s)/operator's name and the facility number, which are required for official records.
5. List the specific California Code of Regulations and Health and Safety Code sections violated, referencing any applicable documentation received.
6. Document the civil penalty amount assessed and the duration of the violation period clearly, ensuring accuracy for record-keeping.
7. Sign the form in the designated areas for both the licensing program analyst and facility representative, confirming the assessment details.
8. Review all entries for completeness and accuracy before finalizing the document.
9. Once completed, save changes, download, and print the form for your records or share it as necessary.

Complete your Lic421 Form online today and ensure compliance with licensing requirements.