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09/21/2012 08:45 12092245262 DELTA REHAB AND CARE PAGE 02/02 <br /> Delta Rehab'fftaLion and Care Center <br /> 1334 South Elam Line Lodi,C.A.95242 <br /> In-service/Continuing Education Attendance Record <br /> Title/Subject: A eA 5,e— VJ 5 e S 0 ,4�k Li VV14-2.J--I r,C <br /> J -�I <br /> Reason: e'!F- Vn <br /> L tJt,5f 4e <br /> Instructor Name/Title: <br /> Q <br /> Date: qI 20112 SUWEnd time: <br /> DSD Signature.- Provider#f 0943 <br /> SipaturOTitle/Shift Date sjlipatarefritle/Sbift Date <br /> A copy of this record shall be maintained by this facility for a period of four years <br /> starting from,the date the first classes were offered. <br /> Received Time Sep'. 21. 2'012 ' 8: 45:A':M No. 0264 <br />