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Renewal is in process <br />OFFICE OF STATEWIDE HEALTH PLANNING AND DEVELOPMENT <br />G�gl�y�ip FACILITIES DEVELOPMENT DIVISION <br />APPLICATION FOR OSHPD PREAPPROVED AGENCY (OPAA) <br />For Office Use Only <br />FOR STRUCTURAL TESTS AND SPECIAL INSPECTIONS <br />OPAA-0010-16 <br />Approved Agency City County <br />State ZIP Code <br />Kleinfelder Inc. Ontario San Bernardino CA 91762 <br />APPLICATION TYPE / FEE <br />Application Type <br />New Application Fee <br />Renewal Fee <br />(Fees are Nonrefundable) <br />(Fees are Nonrefundable) <br />® Combined Testing AND Special Inspection Agency <br />❑ $1,000.00 <br />Z <br />$500.00 <br />❑ Testing Agency ONLY <br />❑ $500.00 <br />❑ $250.00 <br />❑ Special Inspection Agency ONLY <br />❑ $500.00 <br />❑ $250.00 <br />APPLICANT INFORMATION <br />Applicant Name <br />Jeffrey Diaz <br />Position in the Organization <br />Ontario <br />Laboratory Supervisor <br />Agencys Local Name <br />Kleinfelder West, Inc <br />Application Date <br />3t9i2017 <br />Phone Number <br />E-Mail <br />(909) 657-1716 <br />jmdiaz@kieifnetder.com <br />Applicant certifies that all information provided in this application are accurate. <br />Applicant Signature <br />Address of Facility Location (Each facilitylocation requires separate application.) <br />Street <br />620 South Magnolia Avenue, Building'G' <br />City: Count <br />Ontario San Bernardino <br />CAte. Zip Cade: <br />91762 <br />Facility Mailing Address (If different from facility address above.) <br />Street <br />City: <br />State: Zip Code: <br />KEY AGENCY PERSONNEL (Attach additional pages if needed.) <br />Engineering Manager (or equivalent) — Name <br />CA Registration Number <br />Eric Noel <br />C 53513 <br />Expiration Date <br />Title in the Organization <br />Phone Number <br />6-30-2017 <br />Project Manager III <br />(951) 801-3723 <br />FAX Number <br />E-Mail <br />ENoel@kleinfelder.com <br />Alternate to Engineering Manager (if any) — Name <br />CA Registration Number <br />Expiration Date <br />Title in the Organization <br />Phone Number <br />Alternate Phone Number <br />E-mail <br />Access to Safe. Duality Healthcare Environments that Meet Califome's Diverse and 0mamic Needs <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 1 of 19 <br />