ARIZONA DEPARTMENT OF AGRICULTURE
WEIGHTS AND MEASURES SERVICES DIVISION
1688 W. Adams Street, Phoenix, AZ 85007 hps://agriculture.az.gov
Phone: 602‐542‐3578 Fax: 602‐542‐0466
E‐mail: licensing@azda.gov State Ombudsman: 602‐277‐7292
REGISTERED SERVICE AGENCY (RSA)
APPLICATION
LICENSE FEE = $24.00
I cerfy that ______________________________________ (company name) possesses the necessary standards and tesng equipment to service and cerfy the commercial devices and/or vapor recovery systems for
which we are requesng licensure. I also cerfy that the named company has full knowledge of all applicable regulaons (specifically A.R.S. § 3‐3454 and A.A.C. R3‐7‐601 through 604), will operate as an RSA in
compliance with all legal requirements, and will only use cerficaon standards that have been cerfied annually by the device manufacturer and/or NIST‐traceable laboratory.
*OUT OF STATE AGENCIES: If your standards have been cerfied in a state other than Arizona, please enclose a copy of the Cerficaon Report. Test standards shall be cerfied annually under A.A.C. R3‐7‐602(A)(3).
RSA REPRESENTATIVE SIGNATURE DATE
DWM‐161 (rev. 02/2018)
Type of device(s) your agency is qualified to
install, service, or repair:
Small Capacity Scales Large Capacity Scales Fueling Meters
Water Meters LPG Meters Vapor Recovery
Other _____________________
ADDRESS: CITY: STATE: ZIP CODE:
BUSINESS NAME:
PHYSICAL ADDRESS (if previous is a PO Box): CITY: STATE: ZIP CODE:
PHONE: FAX: E‐MAIL:
Does your company currently maintain a license, or has previously maintained a license as a Registered Service Agency with the State of Arizona or any other state*? Yes No
If yes, please indicate the state(s) (including AZ)*: 1. 2. 3. Has your license ever been suspended or revoked? Yes No
STANDARD SERIAL or ID # STANDARD SERIAL or ID # STANDARD SERIAL or ID #
LIST CERTIFICATION STANDARDS that will be used by your RSRs to service and cerfy commercial devices and/or vapor recovery systems:
Please submit completed form to AZDA Licensing by e‐mail at licensing.wmsd@azda.gov or by fax to 602‐542‐0466.
