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
VAPOR RECOVERY REGISTERED SERVICE
REPRESENTATIVE (RSR) APPLICATION
LICENSE FEE = $4.80
(Invoice will be sent to RSA aŌer applicant passes exam)
APPLICANT: I will comply with applicable secons of A.R.S. Title 3, Chapter 19, A.A.C. Title 3, Chapter 7, and CARB Execuve Orders. Falsificaon of any informaon on this form could result in
revocaon or denial of a license. I also understand that I may be subject to civil penales under A.R.S. § 3‐3475 if a violaon occurs.
APPLICANT NAME SIGNATURE DATE
RSA: I cerfy that the applicant meets all legal requirements for an RSR license, and possesses the necessary technical knowledge, reference materials, and cerfied tesng equipment to
perform required RSR dues.
RSA REPRESENTATIVE SIGNATURE DATE
DWM‐162VR (rev. 02/2018)
APPLICANT NAME: EMPLOYED BY: RSA#:
Were you licensed within the past year as an RSR? Yes No If yes, indicate your RSR#: Previous employer’s RSA# (if applicable):
Has your license ever been suspended or revoked? Yes No If yes, indicate the year: Reason for revocaon:
In order to demonstrate compliance with A.A.C. R3‐7‐601(C)(3), please provide the Division with the following informaon:
Indicate relevant experience and equipment and/or system cerficaons:
MANUFACTURER DATE OF CERTIFICATION CERTIFICATION NUMBER
DESCRIPTION OF TRAINING DATE OF TRAINING
Indicate specific technical training on CARB Execuve Orders:
Please submit completed form in person at 1688 W. Adams Street, Phoenix, AZ 85007. To make an appointment call 602‐542‐4373.
