Fillable - AZDA CBG Registration Form 2017 08 02 (Arizona)

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- AZDA CBG Registration Form 2017 08 02 (Arizona)

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Weights and Measures Services Division

1688 W. Adams Street, Phoenix, Arizona 85007

Metrology Laboratory: 4425 W. Olive Avenue, Glendale, AZ 85302

(602) 542-4373 FAX: (623) 939-8586 agriculture.az.gov

DOUGLAS A. DUCEY

Governor

MARK W. KILLIAN

Director

___________________________________________

ARIZONACBGREGISTRATIONFORM

Oneregistrationformisrequiredforeachregisteringfacility.Registrationform(s)mustbesubmittedtotheaboveaddressinadvanceofthe

firstdateofproduction,importation,orhandlingofCBGorAZRBOB.ChangestothisformmustbesubmittedtotheWeightsandMeasures

ServicesDivisionnolaterthanten(10)calendardaysaftertheeffectivedateofthechange.PleaserefertoArizonaAdministrativeCode

R3‐7‐750forfurtherregistration

requirements.

SectionI.BusinessName,Address,AuthorizedAgent’sName,Telephone/FAX.



__________________________________________________________________________________

BusinessName Address  City StateZipCode



_________________________________________________________________________________

BMF#ContactName  Telephone  FAX



SectionII.FacilityType(asdefinedinR3‐7‐701).Thefacilitymayregisterformorethanonetype.



1)Refiner____2)Importer____3)OxygenateBlender____4)Pipeline____5)ThirdPartyTerminal____



_______________________________________________________________________________

FacilityName   Address

CityStateZipCode



_________________________________________________________________________________

ContactName   Telephone   FAX



DesignatedOn‐lineReportingContactInformation

(Thisindividualisresponsibleforfilingandcertifyingreportson‐lineandwillbesentaUserIDandaccesscodeforon‐linereportingbythe

facility.)



_________________________ ____________________________________

DesignatedOn‐line  Telephone  E‐mailAddress

ReportingContact



SectionIII.RecordKeeping.



Arerecordsforthisfacilitykept:On‐Site_____and/orOff‐Site_____?Ifrecordsarekeptoff‐site,pleasecomplete

thefollowing:



________________________________________________________________________________

PrimaryStorageFacilityName Address City  StateZipCode



_________________________________________________________________________________

ContactName   Telephone   FAX

___________________________________________________________________

Page1of2



Weights and Measures Services Division

1688 W. Adams Street, Phoenix, Arizona 85007

Metrology Laboratory: 4425 W. Olive Avenue, Glendale, AZ 85302

(602) 542-4373 FAX: (623) 939-8586 agriculture.az.gov

DOUGLAS A. DUCEY

Governor

MARK W. KILLIAN

Director



SectionIV.

IndependentLaboratoryUse.



WillanindependentlaboratorybeusedtomeettherequirementsofA.A.C.R3‐7‐752(F)orR3‐7‐755(E)?



Yes______No______



If“Yes”,pleasecompletethefollowing:



______________________________________________________________________________________________________

LaboratoryName  Address City  StateZipCode



______________________________________________________________________________________________________

ResponsibleOfficial  Telephone  FAX

Refiners

PleasechooseoneofthefollowingoptionsfromR3‐7‐752(F):



1) IndependentTestingOption1_____,(Independentlaboratorywillcollectandanalyzeeverybatch.)



2) IndependentTestingOption2_____,(Tenpercent[10%]ofthetotalnumberofbatcheswillbe

collectedandanalyzedbytheindependentlaboratory.)



Note: Itistheregistrant’sresponsibilitytocommunicatewiththeirindependentlaboratorythattestresults

aretobesubmittedtotheWeightsandMeasuresServicesDivisiondirectlyfromtheindependentlaboratoryin

thecorrectformatandonthecorrectdate,asstatedwithintheArizonaAdministrativeCode.



SectionV.EPARegistrationNumber.



Ifapplicable,EPARegistrationNumberassuppliedunder40CFR80.76(f):



_________________________________

EPARegistrationNumber



SectionVI.StatementofConsent.



IherebycertifyandattestthatIhavetheauthoritytoactonbehalfofandbind

________________________________________(BusinessName),andthattheinformationprovidedistrueand

accuratetothebestofmyknowledge.Onbehalfof

________________________________________(BusinessName),IherebyprovideconsenttotheWeightsand

MeasuresServicesDivisionor

itsauthorizedagenttocollectsamplesandassessdocumentationandrecordsas

providedinArizonaAdministrativeCodeR3‐7‐752.Iagreethatchangestoanyinformationprovidedinthis

registrationformwillbesenttotheAssociateDirectoroftheWeightsandMeasuresServicesDivisionnolater

thanten

(10)calendardaysaftertheeffectivedateofthechange.



____________________________________________________________________________

Signature   PrintedName   



______________________________________________________________________________

Position    BusinessName   Date

___________________________________________________________________

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Completed 12 August 2020

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