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Renewal is in process <br />QNII•II1CII: QkII•SIfAlfII VWIIIIrII: II1II:AILlfllll lf1II,,,,A' 11III'4IIING AV+II 11Vll'@911:II ::all"MII,:Ntt <br />q�� ,o au II•A�CIIII Il lfllll:S II'kll'Vll:ll.- III'1M1I:IN"If DIVISION <br />APPLICATION FOR OSHPD PREAPPROVED AGENCY (OPAA) <br />FOR STRUCTURAL TESTS AND SPECIAL INSPECTIONS <br />For Office Use Only <br />OPAA-0010-16 <br />Appmvarl Agenny <br />City <br />County <br />State <br />ZIP Cntla <br />Kleinlelder Inc. <br />onlario <br />San Bernardino <br />CA <br />91762 <br />APPLICATION TYPE / FEE <br />Application Type <br />New Application Fee <br />Fees are Nonrefundable <br />Renewal Fee <br />Fees are Nonrefundable <br />Ixl Combined Testing Abp Special Inspection Agency <br />—' $1.000.00 <br />29 $500A0 <br />I esting 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 Ala= Ontsi".O <br />Position in the Organization <br />LahGrairry SuperV'. sol' <br />Agchsy LVeill Nome <br />Kleinfelder West, Inc <br />Appllcallan Datc <br />1/9/2017 <br />raune Nun..... <br />(911!))ab7-171a <br />C-Mna <br />I....lndd, r nn. <br />Applicant certifies that all Information provided In this application are accurate. <br />Applicant Signature - <br />AOr re" _,f Fa6hty I OOa[IOn (FadPo fprCddyfOCytrOP reU!Jrrra' erri"te aDDGcanpn-) <br />Street <br />bA South Magnolia AVenLL r3r111611g G <br />Qty <br />Ontario <br />County <br />San 6cm.sal no <br />Start_ <br />CA <br />Lip C6ae_ <br />017G2 <br />I Ar. Iily M.),I nG Annrf.,..,.. (If Win,not t im fnn,my naa,nRR nbnvn.) <br />St, _!-1 <br />City <br />State_ <br />Do Cade_ <br />KEY AGENCY PERSONNEL(Attacnadditionalpagcsifn(,,cded.) <br />Enginaanng Manager (or equivalent) - Kanle <br />Eric. Noel <br />CA Keg Stratl0n NunnttI <br />C 53513 <br />LW) I.A1011 Jots <br />6-30-2017 <br />TI'Ju. .nv Ong�.u . vi F'nnnc <br />Proh,'t M,ngigcrIII <br />Nunlhcr <br />(9151) f101-117/ i <br />FAX Ncrrlbcr <br />--will <br />ENu�1rt021dn1 Jnerr,.n. <br />Alternate to Erg'. nearing Manager (ifany)- Name <br />CA Nils'tmaan Nwnncr <br />_xp.raann unm <br />I Tle n tnl ❑rganoannn <br />Pncne Ncniber <br />Alternate Phone Number <br />_ms.I <br />.... .0 su&r_ <br />ME <br />STATE OF CALIFI M9--YiVN1 <br />U"A-I-LD-r W AA- I qp (fif2-W'o I eS) <br />_VZ V >017 <br />AND HUMAN SERVICES AGENCY <br />0PAA r101 )-1i' <br />