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01l•IFICII OF:: FAFII::WIIIIrll. 11lll:AILlf11 11 If1II....AIMINIIING ANII.II..)II'VII.II )II"IIMII 14I <br />'7r/rd�hi�p) )y� rs11::•ACIIII__11 .) 'V' Sja w_::. h.N"If .Y vn'�al101M <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 Forni (OSH-AD-367): <br />htt 9/osh d.ca. ov/FDD/Forms/eSPForms/OSH-FD 367-FacDvrntDivPmtForm. df <br />0 <br />DSA-LEA Laboratory Qualification as posted at DSA website: <br />htt siffwww.a s2.d s.ca. ov/DSA/Tracker/A rovedLabs.as x <br />LatestCopyof DSA 100: LEA Progr9mApplic9tion as Submitted to DSA <br />El <br />Latest copy of DSA 220LEA Pro ram On -Site Assessment Report <br />LatAat moy of DSA acre tannA latter of thA Agonr.V into the LEA progrAm. <br />Current Accreditation Certificates including List of Tests and Special Inspections for which the Agency is Accredited <br />El <br />Copy of Test Technician/Individual Special Inspectors License/Certification showinci expiration date(s) <br />Xi <br />OPL Numbrr for Conversion of OPL to OPAA only: OPL-0042-1 S <br />rr <br />OPAA Number for Conversion/Renewal of OPAA only <br />— <br />Other Please Specify): <br />rr <br />Other Please Specify): <br />rr <br />Other Please S ecif : <br />— <br />Other Please Specify): <br />QSHPD Approval <br />L <br />Signature <br />Print Name: Jeffrey Kikumoto <br />Title SE <br />Condition of approval (if applicable). <br />(For Office Use Only) <br />Approval Date: 5/6/2019 <br />Approval Expiration Date: 9/25/2022 <br />STA rE OF CALIFbtft 'tFIIE &tI AND HUMAN SERVICES AGENCY <br />nAr12019 OPAA 004,) 1� <br />I"rtp I!I �f 19 <br />