1. A. The Department may suspend or revoke a permit for any of the following reasons:

   1. 1. A false statement on the permit holder’s application,
   2. 2. The neglect or refusal to examine and report the results of sample specimens given the Analyst permit holder for proficiency testing purposes,
   3. 3. The failure of an Analyst to maintain quality control over equipment or reagents necessary for accuracy in reporting,
   4. 4. Failure to obtain results on proficiency test samples as indicated in R13-10-108(B),
   5. 5. Failure to operate a device according to approved procedures or the failure to analyze blood or other bodily substances according to approved methods, or
   6. 6. The failure by a permit holder to maintain documentation required by this Article or to make it available to Departmental representatives for inspection for purposes of administering this Article.
2. B. When a permit has been suspended or revoked in one or more of the approved methods or devices and there remain one or more methods or devices for which the permittee is approved that are not affected by the revocation or suspension, the permit holder shall return the suspended or revoked permit to the Department. The Department shall issue a replacement permit that shows only those approved methods or devices unaffected by the event leading to the suspension or revocation.
3. C. The provisions of A.R.S. Title 41, Chapter 6, Article 10 are applicable to denials, revocations, suspensions and administrative appeals.

4. 1. Name:

   (Full legal name) (First) (Middle) (Last) (Maiden)

5. 2. Date of Birth:

   (Month) (Day) (Year)

6. 3. Employer:

   (Name)

   (Address)

   (Phone) (Fax)

7. 4. Email address:

8. 5. Education: I have earned a degree from an accredited college or university with 15 or more semester credits or the equivalent of college chemistry, including at least 3 credits in organic chemistry. Yes _____ No _____

   College(s) attended

   (City & State) (Year Graduated) (Degree)

   (City & State) (Year Graduated) (Degree)

9. 6. Check the analytical method(s) for which you require an Analyst permit:

   Gas Chromatography Other:

   I hereby certify that the information submitted in this application is true and correct.

   ____________________________________________________________________________________________________

   (Signature of Applicant) (Date)

   DPS Form Exh A (Rev. 19-1)

10. 1. Name:

    (Full legal name) (First) (Middle) (Last) (Maiden)

11. 2. Employer:

    (Name)

    (Address)

    (Phone) (Fax)

12. 3. Email address:

13. 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

14. 1. Agency Conducting Training:

15. 2. Date and Location of Training:

    (Date) (Location)

16. 3. Arizona Department of Public Safety course approval number:

17. 4. Did applicant successfully complete the course? Pass _____ Fail _____

    (Signature of Instructor) (Print Name) (Date)

    DPS Form Exh B (Rev. 19-1)

18. 1. Name:

    (Full legal name) (First) (Middle) (Last) (Maiden)

19. 2. Employer:

    (Name)

    (Address)

    (Phone) (Fax)

20. 3. Email address:

21. 4. QAS 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

22. 1. Agency Conducting Training:

23. 2. Date and Location of Training:

    (Date) (Location)

24. 3. Arizona Department of Public Safety course approval number:

25. 4. Did applicant successfully complete the course? Pass _____ Fail _____

    (Signature of Instructor) (Print Name) (Date)

    DPS Form Exh C (Rev. 19-1)

26. 1. Name:

    (Full legal name) (First) (Middle) (Last) (Maiden)

27. 2. Employer:

    (Name)

    (Address)

    (Phone) (Fax)

28. 3. Email address:

29. 4. Instructor certificate requested for what device:

    I hereby certify that the information submitted in this application is true and correct.

    ____________________________________________________________________________________________________

    (Signature of Applicant) (Date)

    * * * * * * * * * * * * * * * * * * *

    TO BE COMPLETED BY REGULATOR

30. 1. Arizona Department of Public Safety examination approval number:

31. 2. Did applicant successfully attain Instructor approval? Pass _____ Fail _____

    (Signature of Regulator) (Print Name) (Date)

    DPS Form Exh D (Rev. 19-1)

32. 0. AC TIME

33. 0. AC TIME

    Immediately preceding administration of the tests, subject underwent at least a 15-minute deprivation period:

    From to by

    (Time) (Time) (Name)

    ( ) 1. Display reads “PUSH BUTTON TO START”.

    ( ) 2. Push Start Test button.

    ( ) 3. Follow automated instructions on instrument display.

    ( ) 4. If test record reads “Successfully Completed Test Sequence” go to step 5

    OR

    If test record reads “Not a Successfully Completed Test Sequence”, and subject will be tested again, remove test record and go to step 1

    OR

    If test record reads “Not a Successfully Completed Test Sequence”, and subject will not be tested again, go to
    step 5

    ( ) 5. Remove test record.

    Note: Duplicate breath tests shall be administered at intervals of not less than 5 minutes nor more than 10 minutes apart and the two consecutive tests shall agree within 0.020 alcohol concentration.

    DPS Form Exh G-1 (Rev 05-1)

34. 1. a. Ensure dry gas tank is attached to instrument and contains a standard alcohol concentration solution alcohol standard.

    1. b. Pour a standard alcohol concentration solution into a clean dry simulator and assemble the simulator.

       Ensure that a tight seal has been made. Turn on the simulator and allow temperature to reach 34° C ± 0.2° C

    OR

35. 2. Intoxilyzer 8000 display reads “PUSH BUTTON TO START”
36. 3. Go to the “Control Testing Menu”. Select “D” for dry control test or “W” for wet control test. After selection is made press ENTER.
37. 4. Air blank completed.
38. 5. Standard Calibration Check completed.

39. 6. Air blank completed.

    DPS Form Exh G-3 (Rev 05-01)

40. 1. Clock time check.

41. 2. Date check.

    OPERATIONAL TESTS

42. 1. Alcohol-free subject test result.

43. 2. Error recognition logic system functioning.

    Not a Successfully Completed Test Sequence printed or recorded.

44. 3. Proper sample recognition system.

    Not a Successfully Completed Test Sequence printed or recorded.

    Deficient sample printed or recorded.

45. 4. Standard alcohol concentration solution.

    DPS Form Exh G-5 (Rev 05-01)

46. 0. AC TIME ___________ PASS FAIL 0. AC

47. 0. AC TIME ___________

    PASS FAIL 0. AC

48. 0. AC TIME ___________

    Immediately preceding administration of the tests, subject underwent at least a 15-minute deprivation period:

    From to by

    (Time) (Time) (Name)

    ( ) 1. Display reads “PUSH BUTTON TO START”.

    ( ) 2. Push Start Test button.

    ( ) 3. Follow automated instructions on instrument display.

    ( ) 4. If test record reads “Successfully Completed Test Sequence” go to step 5

    OR

    If test record reads “Not a Successfully Completed Test Sequence”, and subject will be tested again, remove test record and go to step 1

    OR

    If test record reads “Not a Successfully Completed Test Sequence”, and subject will not be tested again, go to
    step 5

    ( ) 5. Remove test record.

    Note: A successfully completed test sequence includes the following:

    - - At least a 15-minute deprivation period.

    - - Successful concurrent diagnostic checks

    - - Successful Concurrent Calibration Check Procedures bracketing the duplicate breath test

    - - Duplicate breath test administered at intervals of not less than 5 minutes nor more than 10 minutes apart and the two consecutive tests agreeing within 0.020 alcohol concentration.

    DPS Form Exh G-6 (Rev 05-01)

49. 0. AC TIME

50. 0. AC TIME

    1. b. If subject test, repeat steps 3 – 6 for duplicate test.
    2. c. If the second subject test is not within 0.020 of the first test, repeat steps 3-6.
    3. d. If the second subject test is within 0.020 of the first test, go to step 7.

    4. e. If the third subject test, go to step 7.

       ( ) 7. Remove test record when printout is complete.

       ( ) 8. Turn off RBT AZ.

       Note: Duplicate breath tests shall be administered at intervals of not less than 5 nor more than 10 minutes and the two consecutive tests shall agree within 0.020 alcohol concentration.

       DPS Form Exh H-1 (Rev 05-01)

    Immediately preceding administration of the tests, subject underwent at least a 15-minute deprivation period:

    From to by

    (Time) (Time) (Name)

    ( ) 1. Depress RBT AZ ON button.

    ( ) 2. Depress zero set button, select subject or quick test.

    ( ) 3. Follow RBT AZ and AS AZ display instructions.

    ( ) 4. Enter case # &/or DL # if required.

    ( ) 5. Device temperature registers between 10° C and 40° C.

    ( ) 6. a. If quick test, go to step 7.

51. 0. ________ AC

    ❏ 3. Mouth Alcohol Subject Test (Proper Sample Recognition):

    Invalid Sample – Begin new deprivation period printed

    ❏ 4. Radio Frequency Interference Test (Error Recognition):

    RFI Detect printed

    ❏ 5. Standard Calibration Check:

52. 0. ________ AC

    ❏ 6. Air Blanks Completed

    ❏ 7. Timer Reset

    Not a Successfully Completed Test Sequence will be printed.

    Instrument is operating properly and accurately. YES ______ NO ______

    COMMENTS:

    _____________________________________________________________________________________________

    _____________________________________________________________________________________________

    _____________________________________________________________________________________________

    SIGNATURE _______________________________________________

    DPS Form Exh I-2 (Iss 19-01)

Exhibit A. Application for Blood Alcohol Analyst Permit

APPLICATION FOR BLOOD ALCOHOL ANALYST PERMIT

ARIZONA DEPARTMENT OF PUBLIC SAFETY

Scientific Analysis Bureau
2102 W. Encanto Blvd.
Phoenix, Arizona 85009
(602) 223-2394

Application for Analyst permit to perform analysis of blood or other bodily substances for alcohol concentration determinations.

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 ____ PERMIT NUMBER _______________

Historical Note

New Exhibit A made by final rulemaking at 12 A.A.R. 1916, effective 9:00 a.m., May 18, 2006 (Supp. 06-2). Exhibit A amended by final rulemaking at 26 A.A.R. 723, effective June 1, 2020 (Supp. 20-2).

Exhibit B

. Application for Breath Alcohol Operator Permit

APPLICATION FOR BREATH ALCOHOL OPERATOR PERMIT

ARIZONA DEPARTMENT OF PUBLIC SAFETY

Scientific Analysis Bureau
2102 W. Encanto Blvd.
Phoenix, Arizona 85009
(602) 223-2394

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) ___________________________________________________________

Historical Note

New Exhibit B made by final rulemaking at 12 A.A.R. 1916, effective 9:00 a.m., May 18, 2006 (Supp. 06-2). Exhibit B amended by final rulemaking at 26 A.A.R. 723, effective June 1, 2020 (Supp. 20-2).

Exhibit C.

Application for Breath Alcohol Quality Assurance Specialist Permit

APPLICATION FOR BREATH ALCOHOL QUALITY ASSURANCE SPECIALIST PERMIT

ARIZONA DEPARTMENT OF PUBLIC SAFETY

Scientific Analysis Bureau
2102 W. Encanto Blvd

.
Phoenix, Arizona 85009
(602) 223-2394

Application for a QAS permit to perform 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) ___________________________________________________________

Historical Note

New Exhibit C made by final rulemaking at 12 A.A.R. 1916, effective 9:00 a.m., May 18, 2006 (Supp. 06-2). Exhibit C amended by final rulemaking at 26 A.A.R. 723, effective June 1, 2020 (Supp. 20-2).

Exhibit D

. Application for Breath Testing Instructor

APPLICATION FOR BREATH TESTING INSTRUCTOR

ARIZONA DEPARTMENT OF PUBLIC SAFETY

Scientific Analysis Bureau
2102 W. Encanto Blvd

.
Phoenix, Arizona 85009
(602) 223-2394

Application for an Instructor certificate to provide Operator and QAS training 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 APPROVAL _____ RENEWAL _____

DO YOU HAVE AN OPERATOR PERMIT(S)? YES _____ NO _____

OPERATOR DEVICE(S) / PERMIT NUMBER(S)?

DO YOU HAVE QAS PERMIT(S)? YES _____ NO _____

QAS DEVICE(S) / PERMIT NUMBER(S)

Historical Note

New Exhibit D made by final rulemaking at 12 A.A.R. 1916, effective 9:00 a.m., May 18, 2006 (Supp. 06-2). Exhibit D amended by final rulemaking at 26 A.A.R. 723, effective June 1, 2020 (Supp. 20-2).

Exhibit E-1. Expired

Historical Note

New Exhibit E-1 made by final rulemaking at 12 A.A.R. 1916, effective 9:00 a.m., May 18, 2006 (Supp. 06-2). Exhibit E-1 expired under A.R.S. § 41-1056(J) at 22 A.A.R. 2054, effective May 31, 2016 (Supp. 16-3).

Exhibit E-2. Expired

Historical Note

New Exhibit E-2 made by final rulemaking at 12 A.A.R. 1916, effective 9:00 a.m., May 18, 2006 (Supp. 06-2). Exhibit E-2 expired under A.R.S. § 41-1056(J) at 22 A.A.R. 2054, effective May 31, 2016 (Supp. 16-3).

Exhibit E-3. Expired

Historical Note

New Exhibit E-3 made by final rulemaking at 12 A.A.R. 1916, effective 9:00 a.m., May 18, 2006 (Supp. 06-2). Exhibit E-3 expired under A.R.S. § 41-1056(J) at 22 A.A.R. 2054, effective May 31, 2016 (Supp. 16-3).

Exhibit E-4. Expired

Historical Note

New Exhibit E-4 made by final rulemaking at 12 A.A.R. 1916, effective 9:00 a.m., May 18, 2006 (Supp. 06-2). Exhibit E-4 expired under A.R.S. § 41-1056(J) at 22 A.A.R. 2054, effective May 31, 2016 (Supp. 16-3).

Exhibit E-5. Expired

Historical Note

New Exhibit E-5 made by final rulemaking at 12 A.A.R. 1916, effective 9:00 a.m., May 18, 2006 (Supp. 06-2). Exhibit E-5 expired under A.R.S. § 41-1056(J) at 22 A.A.R. 2054, effective May 31, 2016 (Supp. 16-3).

Exhibit E-6. Expired

Historical Note

New Exhibit E-6 made by final rulemaking at 12 A.A.R. 1916, effective 9:00 a.m., May 18, 2006 (Supp. 06-2). Exhibit E-6 expired under A.R.S. § 41-1056(J) at 22 A.A.R. 2054, effective May 31, 2016 (Supp. 16-3).

Exhibit F-1

. Expired

Historical Note

New Exhibit F-1 made by final rulemaking at 12 A.A.R. 1916, effective 9:00 a.m., May 18, 2006 (Supp. 06-2). Exhibit F-1 expired under A.R.S. § 41-1056(J) at 22 A.A.R. 2054, effective May 31, 2016 (Supp. 16-3).

Exhibit F-2

. Expired

Historical Note

New Exhibit F-2 made by final rulemaking at 12 A.A.R. 1916, effective 9:00 a.m., May 18, 2006 (Supp. 06-2). Exhibit F-2 expired under A.R.S. § 41-1056(J) at 22 A.A.R. 2054, effective May 31, 2016 (Supp. 16-3).

Exhibit F-3.

Expired

Historical Note

New Exhibit F-3 made by final rulemaking at 12 A.A.R. 1916, effective 9:00 a.m., May 18, 2006 (Supp. 06-2). Exhibit F-3 expired under A.R.S. § 41-1056(J) at 22 A.A.R. 2054, effective May 31, 2016 (Supp. 16-3).

Exhibit F-4

. Expired

Historical Note

New Exhibit F-4 made by final rulemaking at 12 A.A.R. 1916, effective 9:00 a.m., May 18, 2006 (Supp. 06-2). Exhibit F-4 expired under A.R.S. § 41-1056(J) at 22 A.A.R. 2054, effective May 31, 2016 (Supp. 16-3).

Exhibit F-5

. Expired

Historical Note

New Exhibit F-5 made by final rulemaking at 12 A.A.R. 1916, effective 9:00 a.m., May 18, 2006 (Supp. 06-2). Exhibit F-5 expired under A.R.S. § 41-1056(J) at 22 A.A.R. 2054, effective May 31, 2016 (Supp. 16-3).

Exhibit G-1. Standard Operational Procedure, Intoxilyzer Model 8000

OPERATIONAL CHECKLIST

ARIZONA DEPARTMENT OF PUBLIC SAFETY

STANDARD OPERATIONAL PROCEDURE
INTOXILYZER MODEL 8000

DUPLICATE BREATH TEST

SUBJECT NAME DATE

AGENCY OPERATOR

INSTRUMENT SERIAL # LOCATION

TEST RESULTS 0. AC TIME

Historical Note

New Exhibit G-1 made by final rulemaking at 12 A.A.R. 1916, effective 9:00 a.m., May 18, 2006 (Supp. 06-2).

Exhibit G-2. Standard Calibration Check Procedure, Intoxilyzer

Model 8000

THIS REPORT PREPARED PURSUANT TO DUTY IMPOSED BY A.A.C. R13-10-104(A)

ARIZONA DEPARTMENT OF PUBLIC SAFETY

STANDARD QUALITY ASSURANCE PROCEDURES
INTOXILYZER MODEL 8000

STANDARD CALIBRATION CHECK PROCEDURE

QA SPECIALIST AGENCY

DATE TIME

INTOXILYZER SERIAL # LOCATION

( ) 1. Ensure that gas tank is attached to instrument and contains a standard alcohol concentration solution _________AC.

OR

Pour a standard alcohol concentration solution _________AC, into a clean dry simulator and assemble the simulator. Ensure that a tight seal has been made. Turn on the simulator and allow temperature to reach 34° C ± 0.2° C

( ) 2. Intoxilyzer 8000 display reads “PUSH BUTTON TO START”

( ) 3. Go to the “Control Testing Menu”. Select “D” for dry control test or “W” for wet control test. After selection is made press ENTER.

( ) 4. Air blank completed.

( ) 5. Calibration check completed. Test results 0._____________AC.

( ) 6. Air blank completed.

( ) 7. Remove printed record. Attach the record to the completed checklist.

SIGNATURE

DPS Form Exh G-2 (Rev 05-01)

Historical Note

New Exhibit G-2 made by final rulemaking at 12 A.A.R. 1916, effective 9:00 a.m., May 18, 2006 (Supp. 06-2).

Exhibit G-3. Standard Calibration Check Procedure Intoxilyzer , Model 8000 (Option P)

THIS REPORT PREPARED PURSUANT TO DUTY IMPOSED BY A.A.C. R13-10-104(A)

ARIZONA DEPARTMENT OF PUBLIC SAFETY

STANDARD QUALITY ASSURANCE PROCEDURES
INTOXILYZER MODEL 8000

STANDARD CALIBRATION CHECK PROCEDURE

(OPTION P)

Historical Note

New Exhibit G-3 made by final rulemaking at 12 A.A.R. 1916, effective 9:00 a.m., May 18, 2006 (Supp. 06-2).

Exhibit G-4. Standard Quality Assurance Procedure Intoxilyzer, Model 8000

THIS REPORT PREPARED PURSUANT TO DUTY IMPOSED BY A.A.C. R13-10-104(A)

ARIZONA DEPARTMENT OF PUBLIC SAFETY

STANDARD QUALITY ASSURANCE PROCEDURES
INTOXILYZER MODEL 8000

STANDARD QUALITY ASSURANCE PROCEDURE

QA SPECIALIST AGENCY

DATE TIME

INTOXILYZER SERIAL # LOCATION

( ) 1. Display Reads “PUSH BUTTON TO START”

DIAGNOSTIC TESTS

( ) 1. Clock time check.

( ) 2. Date check.

OPERATIONAL TESTS

( ) 1. Alcohol-free subject test result 0._____________AC.

( ) 2. Error recognition logic system functioning.

Not a Successfully Completed Test Sequence printed

( ) 3. Proper sample recognition system.

Not a Successfully Completed Test Sequence printed

Deficient sample printed.

( ) 4. Standard Calibration Check standard 0._____________AC. Result 0._____________AC.

Instrument is operating properly and accurately. YES ______ NO ______

COMMENTS

SIGNATURE

DPS Form Exh G-4 (Rev 05-01)

Historical Note

New Exhibit G-4 made by final rulemaking at 12 A.A.R. 1916, effective 9:00 a.m., May 18, 2006 (Supp. 06-2).

Exhibit G-5. Standard Quality Assurance Procedure Intoxilyze, Model 8000 (Option P)

THIS REPORT PREPARED PURSUANT TO DUTY IMPOSED BY A.A.C. R13-10-104(A)

ARIZONA DEPARTMENT OF PUBLIC SAFETY

STANDARD QUALITY ASSURANCE PROCEDURES

INTOXILYZER MODEL 8000

STANDARD QUALITY ASSURANCE PROCEDURE

(OPTION P)

Display Reads “Push Button to Start”

DIAGNOSTIC TESTS

Historical Note

New Exhibit G-5 made by final rulemaking at 12 A.A.R. 1916, effective 9:00 a.m., May 18, 2006 (Supp. 06-2).

Exhibit G-6. Standard Operational and Quality Assurance Procedure, Intoxilyzer Model 8000

THIS REPORT PREPARED PURSUANT TO DUTY IMPOSED BY A.A.C. R13-10-104(A)

ARIZONA DEPARTMENT OF PUBLIC SAFETY

STANDARD OPERATIONAL AND QUALITY ASSURANCE PROCEDURES

INTOXILYZER MODEL 8000

DUPLICATE BREATH TEST WITH CONCURRENT QUALITY ASSURANCE PROCEDURES

SUBJECT NAME DATE

AGENCY OPERATOR

INSTRUMENT SERIAL # LOCATION

SUBJECT TESTS DIAGNOSTIC CHECKS CALIBRATION CHECKS

Historical Note

New Exhibit G-6 made by final rulemaking at 12 A.A.R. 1916, effective 9:00 a.m., May 18, 2006 (Supp. 06-2).

Exhibit H-1. Standard Operational Procedure Alco Sensor RBT AZ

OPERATIONAL CHECKLIST

ARIZONA DEPARTMENT OF PUBLIC SAFETY

STANDARD OPERATIONAL PROCEDURE
ALCO SENSOR RBT AZ

DUPLICATE BREATH TEST

SUBJECT NAME DATE

AGENCY OPERATOR

LOCATION

RBT AZ SERIAL # ALCO SENSOR AZ SERIAL #

TEST RESULTS 0. AC TIME

Historical Note

New Exhibit H-1 made by final rulemaking at 12 A.A.R. 1916, effective 9:00 a.m., May 18, 2006 (Supp. 06-2).

Exhibit H-2. Standard Calibration Check Procedure Alco Sensor RBT AZ

THIS REPORT PREPARED PURSUANT TO DUTY IMPOSED BY A.A.C. R13-10-104(A)

ARIZONA DEPARTMENT OF PUBLIC SAFETY

STANDARD QUALITY ASSURANCE PROCEDURES
ALCO SENSOR RBT AZ

STANDARD CALIBRATION CHECK PROCEDURE

AGENCY DATE

QA SPECIALIST LOCATION

RBT AZ SERIAL # ALCO SENSOR AZ SERIAL #

( ) 1. Have a standard alcohol concentration solution ready.

This may be a simulator (at 34° C ± 0.2° C) or a dry gas alcohol standard. Standard value: 0._____________AC.

( ) 2. Depress RBT AZ ON button.

Depress Time button.

Enter PIN #.

Depress zero button.

( ) 3. Follow RBT AZ and AS AZ display instructions.

( ) 4. Device temperature registers between 10° C and 40° C.

( ) 5. When AS AZ display reads “CHEK”, introduce standard for 7 seconds; depress the MANUAL button on the

AS AZ at 5 seconds (while continuing to introduce the standard for another 2 seconds.)

( ) 6. Test results 0.___________ AC.

( ) 7. Remove test record when printout is complete.

( ) 8. Turn off RBT AZ.

COMMENTS

SIGNATURE

DPS Form Exh H-2 (Rev 05-01)

Historical Note

New Exhibit H-2 made by final rulemaking at 12 A.A.R. 1916, effective 9:00 a.m., May 18, 2006 (Supp. 06-2).

Exhibit H-3. Standard Quality Assurance Procedure Alco Sensor RBT AZ

THIS REPORT PREPARED PURSUANT TO DUTY IMPOSED BY A.A.C. R13-10-104(A)

ARIZONA DEPARTMENT OF PUBLIC SAFETY

STANDARD QUALITY ASSURANCE PROCEDURES
ALCO SENSOR RBT AZ

STANDARD QUALITY ASSURANCE PROCEDURE

AGENCY DATE

QA SPECIALIST LOCATION

RBT AZ SERIAL # ALCO-SENSOR AZ SERIAL #

( ) 1. Have a standard alcohol concentration solution ready.

This may be a simulator (at 34° C ± 0.2° C) or a dry gas alcohol standard. Standard value: 0._____________AC.

( ) 2. Depress RBT AZ ON button.

Depress Time button.

Enter PIN #.

Depress zero button.

( ) 3. Follow RBT AZ and AS AZ display instructions.

( ) 4. Device temperature registers between 10° C and 40° C.

( ) 5. When AS AZ display reads “CHEK”, introduce standard for 7 seconds; depress the MANUAL button on the

AS AZ at 5 seconds (while continuing to introduce the standard for another 2 seconds.)

( ) 6. Test results 0. AC.

( ) 7. Remove test record when printout is complete.

( ) 8. Turn off RBT AZ.

( ) 1. Date and time correct.

( ) 2. Alcohol-free subject test result 0.______________ AC.

( ) 3. Proper sample recognition system.

( ) 4. Fuel cell response time for a standard solution.

Standard value: AC. Time sec.

( ) 5. Controls, displays, and printer worked correctly during the above quality assurance procedures.

COMMENTS

SIGNATURE

DPS Form Exh H-3 (Rev 05-01)

Historical Note

New Exhibit H-3 made by final rulemaking at 12 A.A.R. 1916, effective 9:00 a.m., May 18, 2006 (Supp. 06-2).

Exhibit H-4. Standard Calibration Procedure Alco Sensor RBT AZ

THIS REPORT PREPARED PURSUANT TO DUTY IMPOSED BY A.A.C. R13-10-104(A)

ARIZONA DEPARTMENT OF PUBLIC SAFETY

STANDARD QUALITY ASSURANCE PROCEDURES
ALCO SENSOR RBT AZ

CALIBRATION

AGENCY DATE

QA SPECIALIST LOCATION

RBT AZ SERIAL # ALCO-SENSOR AZ SERIAL #

( ) 1. Have a standard alcohol concentration solution ready.

This may be a simulator (at 34° C ± 0.2° C) or a dry gas alcohol standard. Standard value: 0.______________ AC.

( ) 2. Depress RBT AZ ON button.

( ) 3. Depress Time button, enter PIN #, depress #1 button.

( ) 4. Follow RBT AZ and AS AZ display instructions.

( ) 5. Device temperature registers between 23° C and 27° C.

( ) 6. After a blank reading of 0.000 is displayed and the standard value is displayed, depress F3.

( ) 7. When AS AZ display flashes “CAL”, introduce standard for 7 seconds; depress the MANUAL button on the
AS AZ at 5 seconds (while continuing to introduce the standard for another 2 seconds.)

( ) 8. Remove test record when printout is complete.

( ) 9. Run a calibration check on the Standard Calibration Check Procedure.

Test results: AC.

COMMENTS

SIGNATURE

DPS Form Exh H-4 (Rev 05-01)

Historical Note

New Exhibit H-4 made by final rulemaking at 12 A.A.R. 1916, effective 9:00 a.m., May 18, 2006 (Supp. 06-2).

Exhibit I-1

. Operational Checklist

Standard Operational Procedure

, Arizona Department of Public Safety, Intoxilyzer Model 9000

, Duplicate Breath Test

OPERATIONAL CHECKLIST

STANDARD OPERATIONAL PROCEDURE

ARIZONA DEPARTMENT OF PUBLIC SAFETY

INTOXILYZER MODEL 9000

DUPLICATE BREATH TEST

SUBJECT NAME _________________________________________ DATE ________________________

AGENCY __________________________________ OPERATOR & BADGE ________________________

INTOXILYZER SERIAL # _________________________ DEPRIVATION BY ______________________

❏ 1. Ensure proper deprivation period

❏ 2. Push the start button on the screen

❏ 3. Follow automated prompts on the instrument display

Note: Duplicate breath tests shall be administered at intervals of not less than 5 minutes nor more than 10 minutes
apart and the two consecutive tests shall agree within 0.020 alcohol concentration.

COMMENTS:

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

SIGNATURE _________________________________________________

DPS Form Exh I-1 (Iss 19-01)

Historical Note

Exhibit I-1 made by final rulemaking at 26 A.A.R. 723, effective June 1, 2020 (Supp. 20-2).

Exhibit I-2.

Arizona Department of Public Safety

, Intoxilyzer Model 9000

, Periodic Maintenance, Standard Calibration Check and

Standard Quality Assurance Procedure

THIS REPORT PREPARED PURSUANT TO DUTY IMPOSED BY A.A.C. R13-10-104(A)

ARIZONA DEPARTMENT OF PUBLIC SAFETY

INTOXILYZER MODEL 9000

PERIODIC MAINTENANCE, STANDARD CALIBRATION CHECK AND

STANDARD QUALITY ASSURANCE PROCEDURE

QA SPECIALIST ______________________________________ AGENCY ______________________________

DATE ___________________________TIME _______________________

INTOXILYZER SERIAL # _______________________________________

❏ 1. Ensure that gas tank is attached and contains a standard alcohol concentration ___________ AC.

DIAGNOSTIC TESTS

❏ 1. Clock time check

❏ 2. Date check

OPERATIONAL TESTS

❏ 1. Deficient Subject Test (Proper Sample Recognition):

Deficient Sample printed

❏ 2. Alcohol-free Subject Test (Proper Sample Recognition):

Historical Note

Exhibit I-2 made by final rulemaking at 26 A.A.R. 723, effective June 1, 2020 (Supp. 20-2).

Historical Note

New Section made by final rulemaking at 12 A.A.R. 1916, effective 9:00 a.m., May 18, 2006 (Supp. 06-2).