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T� OFFICE OF STATEWIDE HEALTH PLANNING AND DEVELOPMENT <br />FACILITIES DEVELOPMENT DIVISION <br />List of Attachments Supporting the Agency's Approval (Check all that apply) <br />Yes <br />Enclosure Type <br />® <br />OSHPD Facilities Development Division (FDD) Payment Form (OSH-AD-367): <br />hfti?://oshpd.ca.gov/FDD/Forms/eSPForms/OSH-FD 367-FacDvmtDivPmtForm. <br />® <br />df <br />DSA-LEA Laboratory Qualification as posted at DSA website: <br />hftps://www.apps.dgs.ca-gov/tracker/ApgrovedLabs.asg)x <br />Latest Copy of DSA 100: LEA Program Application as Submitted to DSA <br />® <br />® <br />Latest copy of DSA 220: LEA Program On -Site Assessment Report <br />® <br />Latest copy of DSA acceptance letter of the Agency8gency into the LEA program. <br />M <br />Current Accreditation Certificates including List of Tests and Special Inspections for which the Agency is Accredited <br />® <br />Copy of Test Technician/Individual Special Inspectors License/Certification showing expiration date(s) <br />® <br />OPL Number for Conversion of OPL to OPAA only: OPL-0045-10 <br />El <br />OPAA Number for Conversion/Renewal of OPAA only: <br />El <br />Other Please Specify): <br />11 <br />Other Please Specify): <br />Other Please Specify): <br />El <br />Other Please Specify): <br />OSHPD Approval (For Office Use Only) <br />Signature: ���/�v �_i Approval Date: 3/28/17 <br />Print Name: M. R. Karim <br />Title: SHFR <br />Condition of approval (if applicable): <br />"Access to Safe. Quality Heal[hcare Environments that Mee[ COtfi mla'0 Diverse and Dynamic Neetls" <br />Approval Expiration Date: July 1, 2020 <br />OSHPD <br />STATE OF CALIFORNIA — HEALTH AND HUMAN SERVICES AGENCY <br />OSH-FD-OPAA-100 (6/24/2016) <br />3/28/2017 OPAA-0010-16 <br />Page 19 or 19 <br />