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011FIFICI.0IF:FAlfll.WIIII)II.IIIII.AILlfllllII..»II,,,,Ab1141I4IllNGAP+dll,6II,JIIVII.II(NIFIKlENT <br />10 <br />List of Attachments Supporting the Agency's Approval (Check all that apply) <br />Yes <br />Enclosure Type <br />OSHPD Facllltles Development Dlvlslon (FDD) Payment Form (OSH-AD-367): <br />htt 9/osh d.ca. ov/FDD/Forms/eSPForms/OSH-FD 367-FacDvm[DivPmtFOrm. df <br />0 <br />DSA-LEA Laboratory Qualification as posted at DSA website: <br />httl3s ffwww.ar)i)s.dqs.ca.gov/tracker/Ar)provedLabs.aspx <br />0 <br />Latest Copy of DSA 100: LEA Program Application as Submitted to DSA <br />-x <br />Latest copy of DSA 220: LEA Program On -Site Assessment Report <br />17 <br />Lalesl copy of DSA acceptance lever of the A(lericy into the LEA ro ram. <br />0 <br />Current Accreditation Certificates including List of Tests and Special Inspections for which the Agency is Accredited <br />Ill <br />Copy of Test Tech n icianfl nd ivid ual Special Inspector's License/Certi fic3 Lion showing expiration dale(s) <br />7 <br />OPL Number for Conversion of OPL to OPAA only: OPL-0045-10 <br />— <br />OPAA Number for Conversion/Renewal of OPAA only. <br />O <br />Other Please Specify): <br />Other Please S ecifv : <br />— <br />Other Please Specify): <br />O <br />Other Please S ecl <br />OSHPD Approval (Eor Office Use Only) <br />Signature !`, , �C�_ri' _ 111—" <br />Print Name: M. R. Karim <br />Title SHFR <br />Condition of approval (if applicable) <br />_, .,:�fr. <br />- <br />Approval Date: 3/28/17 <br />Approval Expiration Date: July 1, 2020 <br />I <br />STATE OF CALIFI6 M=Yi'EAL' M AND HUMAN SERVICES AGENCY <br />OSPI-I-LD-r W AA- 1 qp (G/2-W'o I eS) <br />_H7 /2017 0PAA-r10IY1i' <br />r" ,q4 19 of 19 <br />