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Arizona Administrative Code (Last Updated: November 17, 2016) |
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Title 13. PUBLIC SAFETY |
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Chapter 10. DEPARTMENT OF PUBLIC SAFETY ALCOHOL TESTING |
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Article 1. DETERMINATION OF ALCOHOL CONCENTRATION |
EXHIBIT B
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APPLICATION FOR BREATH ALCOHOL OPERATOR PERMIT
ARIZONA DEPARTMENT OF PUBLIC SAFETY
Scientific Analysis Bureau 2102 W Encanto Blvd Phoenix, Arizona 85009
(602) 223-2394
DO NOT WRITE IN THIS AREA
Permit # Date issued Approved by
Application for an Operator permit to perform alcohol concentration determinations and associated quality assurance procedures on an approved device.
TO BE COMPLETED BY APPLICANT - PLEASE PRINT CLEARLY
(ALL ITEMS MUST BE COMPLETED OR APPLICATION WILL NOT BE ACCEPTED)
IS THIS APPLICATION FOR? INITIAL PERMIT
RENEWAL
DO YOU HAVE AN OPERATOR PERMIT(S)? YES NO
OPERATOR DEVICE(S) / PERMIT NUMBER(S)
1. Name:
(Full Legal Name) (Last) (First) (Middle) (Maiden)
Name:
(As you want it to appear on permit) (Last) (First) (Middle – optional)
2. Employer:
(Name)
3. Email address:
4. Operator permit requested for what device(s): I hereby certify that the information submitted in this application is true and correct.
(Signature of Applicant) Badge # (Date)
* * * * * * * * * * * * * * * * * * *
TO BE COMPLETED BY INSTRUCTOR
1. Agency Conducting Training:
2. Date and Location of Training:
(Date) (Location)
3. Arizona Department of Public Safety course approval number:
4. Did applicant successfully complete the course? Pass Fail
(Signature of Instructor) (Print Name) (Date) DPS Form Exh B (Rev 05-1)