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�� OFFICE OF STATEWIDE HEALTH PLANNING AND DEVELOPMENT <br />T��� FACILITIES DEVELOPMENT DIVISION <br />�4�"r <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 />http://oshi)d.ca.gov/FDD/Forms/eSPForms/OSH-FD 367-FacDvmtDivPmtForm. df <br />® <br />DSA-LEA Laboratory Qualification as posted at DSA website: <br />https://www.apps2.dgs.ca.gov/DSA/Tracker/ApprovedLabs.aspx <br />® <br />Latest Copy of DSA 100: LEA Program Application as Submitted to DSA <br />® <br />Latest copy of DSA 220: LEA Program On -Site Assessment Report <br />Latest copy of DSA acceptance letter of the Agency into the LEA program. <br />® <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 Inspector's License/Certification showing expiration date(s) <br />® <br />OPL Number for Conversion of OPL to OPAA only: OPL-0042-15 <br />OPAA Number for Conversion/Renewal of OPAA only: <br />Other Please Specify): <br />Other Please Specify): <br />Other Please Specify): <br />Other Please Specify): <br />OSHPD Approval (For Office Use Only) <br />Signature: y Approval Date: 5/6/2019 <br />Print Name: Jeffrey Kikumoto Approval Expiration Date: 9/25/2022 <br />Title: SE <br />Condition of approval (if applicable): <br />'Access to Safe. Quality Healthcare Environments that Meet Gelfornia's Diverse and Dvnamic Needs" Abu O S i" f P D <br />STATE OF CALIFORNIA — HEALTH AND HUMAN SERVICES AGENCY <br />OSH-FD-OPAA-100 (03101 /2018) <br />5/6/2019 OPAA-0042-16 Page 19 of 19 <br />