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Target Responsible Action Resource Material <br /> Date Person <br /> Meets county or city land use Documentation in: <br /> ordinance: <br /> Permit issued: <br /> City: Business license: <br /> County: <br /> Tribal: <br /> (For Tribal Programs Only) _ <br /> REGULATORY REFERENCE: • <br /> WAC 388-877B-0405(2)(c): <br /> (i) A copy of the application for a registration certificate from the Washington state board of pharmacy. <br /> (ii)A copy of the application for licensure to the Federal Drug Enforcement Administration <br /> (iii)A copy of the application for certification to the Federal CSAT SAMHSA <br /> (iv)A copy of the application for accreditation by an accreditation body approved as an opioid treatment program accreditation <br /> body by the Federal CSAT SAMHSA <br /> The application will require completion of an American with Disabilities Act(ADA)checklist and a floor plan of the proposed site. <br /> Obtain licensure from Drug License Number: <br /> Enforcement Administration <br /> (DEA) <br /> Obtain registration with Board of Registration Number: <br /> Pharmacy(BOP) <br /> Obtain certification with Federal Federal CSAT Number. <br /> CSAT—SAMHSA <br /> Identified Accreditation Body Accreditation Number: <br /> • <br /> File name: f:lsharedlsectionslcertlOTP\Provider Request Forms 2014+10TP Comm Rel Plan-App D-115/17 <br /> Page 7 of 15 <br />