Fill - Free fillable Device License Application/ Placed- In- Service Report (PISR) (Arizona) PDF form

INSTRUCTIONSFORCOMPLETINGTHEDEVICELICENSEAPPLICATION/PLACED‐IN‐SERVICEREPORT…



NOTE:ThisformmaybecompletedbythecommercialdeviceOwner/LicenseeoraRegisteredServiceRepresentative(RSR).Ifacommercialdevicerequirescalibrationand/orsealingbeforeitmaybeplacedintocommercial

use,anRSRshallbethepersonauthorizedtoperformthisserviceandcompletetheform.Allcommercialdevices

licensedwithintheStateofArizonashallcomplywiththerequirementsoutlinedintheArizonaRevised

Statutes(A.R.S.)Title3,Chapter19,ArizonaAdministrativeCode(A.A.C.)Title3,Chapter7,andNISTHandbook44.



BUSINESSINFORMATION…

1. ProvidetheBUSINESSNAME,PHYSICALADDRESS,andLOCATIONCONTACTinformation.PleaseindicatetheBMF#ifonehaspreviouslybeenissued.

2. ProvidetheOWNER/LICENSEEandBILLINGinformation.TheLOCATIONE‐MAILaddressprovidedwillbeautomaticallyenrolledtoreceivelicenserenewalnotificationsandinvoices.Ifane‐mailaddress

isnot

provided,renewalnotificationsandinvoiceswillbesentbymailtotheBILLINGADDRESS.

3. IftheOWNER/LICENSEEisanINDIVIDUAL,aStatementofLawfulPresenceformmustbecompletedandsubmittedtotheDivisionalongwiththeDeviceLicenseApplication.Thisformisavailableonlineat:

https://agriculture.az.gov

usingtheFORMFINDERprovidedatthebottomofthepage.

4. IfaRegisteredServiceAgency(RSA)/RegisteredServiceRepresentative(RSR)installs,repairs,orremovesthedevice,theREGISTEREDSERVICEAGENCY,RSA#,andRSR#informationboxesmustbecompleted.



DEVICEINFORMATION:

1. IndicatetheDEVICETYPEusingthecheckboxesprovidedontheform.

2. IfthedeviceiscalibratedbyanRSRaspartoftheinstallationorrepair,theRSRmustnotetheSERIALNUMBERSoftestequipmentusedtocalibratethecommercialdevice(s)inthe“RSAEQUIPMENTSERIAL#’s”



box.

3. Usingaseparatelineforeachdevice,completethedeviceinformation.SERVICECODE,FEECODE(alistoffeecodesisincludedwiththisapplication),andSERIALNUMBERarerequiredforeachdevicenotedon

theform.TheNTEPCertificateofConformance(CC)numbermustbeprovidedfor

devicesplacedintoserviceafterJanuary1,1975.Timingdevicessuchascarwashmachines,laundrydryers,andcompressedair

machinesaswellaslinearmeasuringdevicesdonotrequireanNTEPCertificateofConformance.ATAGNUMBERisrequiredforalldevicesbeingrepairedasaresultofanofficial

inspectionbytheDivision.



SUBMITTINGTHEDEVICELICENSEAPPLICATION/PLACED‐IN‐SERVICEREPORT:

1. TheOwner/LicenseeandRSR(ifapplicable)mustsignanddatetheform.

2. CompletedformsmustbesenttotheDivisionwithin7calendardaysoftheservicedate.Formsmaybee‐mailedtolicensing@azda.gov(preferred),sentbyfaxto602‐542‐0466,ormailedtotheaddress

providedatthetopoftheform.

3. Additionalformsmaybeusedwhentherearemorethan10devices.Pleasenotethetotalnumberofpagesinthespaceprovidedonthetoprightcorneroftheform.

4. FormsmayberejectedbytheDivisionforincompleteand/orincorrect

information.



VIOLATIONS/ENFORCEMENTACTION:

ThedeviceOwner/Licenseeisresponsiblefortheaccuracyofthecommercialdevice.AcivilpenaltymaybeissuedunderA.R.S.§3‐3475totheOwner/LicenseeifthedevicedoesnotcomplywithA.R.S,A.A.C.,orNIST

Handbook44requirements.AcivilpenaltymaybeissuedtotheRSRifthis

formisincomplete,incorrect,ornotsubmittedtotheDivisionwithintherequiredtimeframe.



PURSUANTTOA.R.S.§41‐1079,THEFOLLOWINGINFORMATIONISPROVIDEDTOTHEOWNER/LICENSEEOFACOMMERCIALDEVICE…

AlicenseisrequiredforanydeviceasdefinedbyA.R.S.§3‐3401(13).The licensemustbeobtainedwithin30daysfollowing thefirstdayofcommercialusefororiginalinstallationsofeachdevice.Ontransferofalicense,

newlicenseesshallnotifytheDivisionbysubmittingtheCHANGEOF

OWNERSHIPformavailableathttps://agriculture.az.govusingtheFORMFINDERprovidedatthebottomofthepage.NTEP‐approveddevicesshallbe

theonlydevicesallowedforcommercialuse.TocheckifadevicehasanactiveNTEPCertificateofConformancevisitthefollowingwebsite:http://www.ncwm.net/ntep/cert_search



TheDeviceLicenseApplication/Placed‐In‐ServiceReportmustbecompletedandsignedbytheOwner/LicenseeandsubmittedtotheDivisionwithin7calendardaysoftheservicedate.ARegisteredServiceRepresentative

orDivisionInvestigatormaycompletethelicenseapplicationdetailfortheOwner/Licensee,however,theOwner/Licenseemustsigntheapplication

acknowledgingaccuracyoftheinformationandcertifyingtoabideby

pertinentlawsandadministrativerules.TheDivisionwillreviewandprocesstheapplicationaccordingtothelicensingtimeframerulesprovidedbelow.TheOwner/Licenseewillbebilledforthelicensefeeofeachdevice

andmustremittheamountin

fullpriortothelicensebeingissued.



COMMERCIALDEVICELICENSINGTIMEFRAMES(A.A.C.Title3,Chapter7,Article1,Table1):



AUTHORITY ADMINISTRATIVEREVIEW RESPONSETO

COMPLETIONREQUEST

SUBSTANTIVE

COMPLETENESSREVIEW

RESPONSETOADDITIONAL

INFORMATION

OVERALL

TIME‐FRAME

A.A.C.R3‐7‐201 14days 28days 30days 30days 44days



AGENCYCONTACTS:

AZDALicensing:602‐542‐3578orlicensing@azda.gov|Technical&ComplianceQuestions:602‐771‐4939ordwm@azda.gov|StateOmbudsman:602‐277‐7292

CODE DESCRIPTION AMOUNT CODE DESCRIPTION AMOUNT

WEIGHING DEVICES - A.R.S. 3-3452(A) LIQUID MEASURING DEVICES LPG (METERS) - A.R.S. 3-3452(A)

001 0-500 pound capacity $12.00 027 Small bottle fill measuring devices $24.00

002 501-2,000 pound capacity $18.00 028 Motor fuel measuring devices, uncompensated $24.00

003 2,001-7,500 pound capacity $36.00 029 Motor fuel measuring devices, temperature compensating $48.00

104 7,501-20,000 pound capacity $80.00 030 Motor fuel measuring devices, keylocks $48.00

004 20,001-60,000 pound capacity $120.00 031 3/4" and 1" meters, uncompensated $48.00

005 60,001 pound capacity and greater $180.00 032 1 1/4", 1 1/2" and 1 3/4" meters, uncompensated $72.00

039 Portable Batch Plants Varies 033 2" meters and larger, uncompensated $72.00

Livestock scales must be licensed if used more than 30 days/yr. 034 1 1/4", 1 1/2" and 1 3/4" meters, temp compensating $90.00

035 2" meters and larger, temperature compensating $96.00

LIQUID METERING DEVICES (METERS) OTHER THAN

036 3/4" and 1" meters, temperature compensating $54.00

LIQUIFIED PETROLEUM GAS (LPG) - A.R.S. 3-3452(A)

040 Natural gas filling devices $48.00

006 Maximum 12 gallons per minute (gpm) $12.00

007 Maximum 13-150 gpm $36.00

MISCELLANEOUS DEVICES - A.R.S. 3-3452(A)

008 Maximum 151-500 gpm $90.00

009 Maximum 501-1,000 gpm $138.00 301 Other linear measuring devices $12.00

010 Maximum 1,001 gpm and over $168.00 302 Other time measuring mechanical, electrical & electronic devices $12.00

300 All mechanical and electronic counting devices $12.00

MOTOR FUEL DISPENSERS OTHER THAN FOR LPG

A.R.S. 3-3452(A) OTHER FEES AND PENALTIES

011 One meter or blending valve

(includes Diesel Exhaust Fluid (DEF))

$15.00 050 Public Weighmaster - A.R.S. 3-3452(C) $48.00

012 Two meters or blending valves $30.00 048 Deputy Weighmaster - A.R.S. 3-3452(C) $0.00

013 Three meters or blending valves $45.00 049 Limited Weighmaster - A.R.S. 3-3452(C) $0.00

014 Four meters or blending valves $60.00 051 Registered Service Agency (RSA) - A.R.S. 3-3452(C) $24.00

015 Five meters or blending valves $75.00 052 Registered Service Representative (RSR) - A.R.S. 3-3452(C) $4.80

016 Six meters or blending valves $90.00 053 Metrology Certification - A.R.S. 3-3416(H) $110/HOUR

017 Seven meters or blending valves $105.00 ($50 MIN.)

018 Eight meters or blending valves $120.00

054 Commercial Livestock Scales - A.R.S. 3-3451(E) Same as

device fee

019 High volume (over 19 gpm) diesel per

hose &

nozzle

$15.00 056 VR Stage I Area A, Authority to Construct -

A.R.S. 3-3512(D)

$250.00

020 Key lock, limited access w/ accumulators, per

hose & nozzle

$22.50 057 VR Stage I Area B, Authority to Construct

- A.R.S. 3-3512(D)

$250.00

022 Remote indicator and/or control unit (accessory

only)

$22.50 058 VR Stage II, Authority to Construct - A.R.S. 3-3515(D) $250.00

060 Public Record Request - A.R.S. 39-121.01(D)(1) Varies

Commercial and Non-Commercial Requests

211 One meter or blending valve $30.00 Copies $.20/page

212 Two meters or blending valves $60.00 Computer Reports $.02/kb

213 Three meters or blending valves $90.00 CDs $1.00/disc

214 Four meters or blending valves $120.00 Commercial Requests (includes Non-Comerical Fees) $.15/record

215 Five meters or blending valves $150.00 Over 30 minutes staff time $25/hour

216 Six meters or blending valves $180.00 061 Civil Penalty - ARS 41-2115A Varies

217 Seven meters or blending valves $210.00 062 Credits Varies

218 Eight meters or blending valves $240.00 063

LATE PAYMENT PENALTY - A.R.S. 3-3452(F) SEE BELOW

099 Forms and Manuals Varies

(Revised 09/2017)

VAPOR RECOVERY TEST (AREA A)

LATE PAYMENT PENALTY: For each 30 day period past the due date, an additional penalty is imposed in increments of 20%. If all outstanding charges are

not paid within 120 days of the due date, the license shall automatically be cancelled. It is illegal to operate a commercial device, or perform the duties of a

public weighmaster, deputy public weighmaster, RSA, or RSR without a valid license.

FEE CODES, FEES, AND PENALTIES

EFFECTIVE 09/01/2017

ARIZONA DEPARTMENT OF AGRICULTURE

WEIGHTS AND MEASURES SERVICES DIVISION

1688 W. Adams Street, Phoenix, AZ 85007 hƩps://agriculture.az.gov

Phone: 602‐542‐3578 Fax: 602‐542‐0466 E‐mail: licensing@azda.gov

State Ombudsman: 602‐277‐7292

DEVICE LICENSE APPLICATION

PLACED‐IN‐SERVICE REPORT

A.R.S. § 3‐3414 PAGE ___ of ___

BMF # (IF NEW LOCATION WRITE “NEW”): BUSINESS NAME:

OWNER/LICENSEE: BILLING PHONE:

PHYSICAL ADDRESS: ZIP CODE: CITY:

LOCATION CONTACT(S): STORE # (IF APPLICABLE):

PHONE: FAX: LOCATION E‐MAIL:

BILLING ADDRESS: CITY: STATE: ZIP CODE:

RSA #: RSR #: REGISTERED SERVICE AGENCY:

DEVICE TYPE LOCATION CODES (Scales Only) RSA EQUIPMENT SERIAL #’s:

Scales LPG

Fueling Device Other

B: Bakery D: Deli

M: Meat Dept. O: Other

P: Produce R: Register

SERVICE

CODE

FEE

CODE

MANUFACTURER MODEL SERIAL #

NTEP Cerﬁcate of

Conformance # (CC)

LOCATION

CODE OR

TAG #

OWNER/LICENSEE: I will abide by Arizona law pertaining to device use and licensing speciﬁed in A.R.S. Title 3, Chapter 19, and am subject to civil penalty if a violaon occurs (A.R.S. § 3‐3475).

OWNER/LICENSEE NAME SIGNATURE DATE

RSA/RSR: I have complied with all Arizona legal requirements relang to the Division’s RSA/RSR program and am subject to a civil penalty if a violaon occurs (A.R.S. § 3‐3475).

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Fillable Device License Application/ Placed- In- Service Report (PISR) (Arizona)

Fill Online, Printable, Fillable, Blank Device License Application/ Placed- In- Service Report (PISR) (Arizona) Form

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