TEST CERTIFICATION
The undersigned certifies under penalty of perjury that:
________________________________________________
________________________________________________
____________
Signature
____________
Title
____________
Business Address and Phone
BREATHALYZER MAINTENANCE AND CHEMICAL CERTIFICATION
I, ____________________, do certify under penalty of perjury as follows:
I am a Breathalyzer technician possessing a valid permit or certificate issued to me by the state toxicologist by virtue of his rules, WAC 448-12 and RCW 46.61.506.
On __________(date) at __________(time) I examined, tested and calibrated a Breathalyzer machine with serial No. __________ using a sealed ampul of chemicals with control No. __________ according to the methods established and approved by the state toxicologist.
I further certify that said machine was, on that date, in proper working order, and that the chemicals in ampuls with the above control number are suitable for use in this machine.
__________________
Signature of Technician
Dated: _________________________
BAC VERIFIER DATA MASTER CERTIFICATION
I, ____________________, do certify under penalty of perjury as follows:
I am employed by ___________________________________________and am certified by the state toxicologist by virtue of applicable regulations and statutes.
On __________(date) at __________(time) I examined, tested and certified a BAC Verifier Data Master instrument with serial No. __________according to the methods established and approved by the state toxicologist.
I further certify that said instrument was, on that date, in proper working order.
Signature of Technician
Dated: _________________________
BAC VERIFIER DATA MASTER SIMULATOR SOLUTION CERTIFICATION
I, ____________________, do certify under penalty of perjury as follows:
I am employed by the Washington State Toxicology Laboratory, and a part of my responsibilities include preparing and testing the simulator solutions for the BAC Verifier Data Master breath test instrument. I possess the following qualifications:
_______________________________________________.
The simulator solution, Lot Number __________ was prepared in the Washington State Toxicology Laboratory. I examined and tested this solution. It was found to conform to those standards established by the state toxicologist for the certification of simulator solution.
Dated:__________________________
_______________________________
Signature
BAC DATAMASTER SIMULATOR THERMOMETER CERTIFICATION
I, ____________________, do certify under penalty of perjury under the laws of the State of Washington that the following is true and correct:
I am employed by the Washington State Patrol and am certified as a Technician by the state toxicologist by virtue of applicable regulations and statutes.
On __________(date) at __________(time) I tested and certified simulator thermometer __________(serial number) which is installed in simulator ____________(serial number) and which is attached to BAC Data Master __________(serial number). In performing the test I employed a protocol approved by the state toxicologist. I found the thermometer to comply with the standards for accuracy as required by the state toxicologist. The certification of this thermometer is valid for one year from the date of this certification.
______________________
Signature of Technician
Dated: _________________________
Location: ________________________(city and state)
I further certify that said machine was not in proper working order on __________(date) at __________M.
I further certify that I repaired or corrected said machine as required on __________(date) and as of that date at __________M. said machine was again in proper working order (and that the chemicals in ampuls with the above control number are suitable for use in this machine.) (Cross out bracketed language if not applicable.)
Dated: _________________________
_________________________
Technician
CERTIFICATION CONCERNING DESIGN AND CONSTRUCTION OF ELECTRONIC SPEED MEASURING DEVICES AND LASER SPEED MEASURING DEVICES
I, ____________________, do certify under penalty of perjury as follows:
I am employed with ____________________as a ________________________________.
I have been employed in such a capacity for _____ years. Part of my duties include supervising the maintenance and repair of all electronic and laser speed measuring devices (SMDs) used by ____________________(name of agency).
This agency currently uses the following SMDs:
(List all SMDs used and their manufacturers and identify which SMDs use laser technology.)
I have the following qualifications with respect to the above stated SMDs:
(List all degrees held and any special schooling regarding the SMDs listed above.)
This agency maintains manuals for all of the above stated SMDs. I am personally familiar with those manuals and how each of the SMDs are designed and operated. On _____(date) testing of the SMDs was performed under my direction. The units were evaluated to meet or exceed existing performance standards. This agency maintains a testing and certification program. This program requires:
(State the program in detail.)
Based upon my education, training, and experience and my knowledge of the SMDs listed above, it is my opinion that each of these electronic pieces of equipment is so designed and constructed as to accurately employ the Doppler effect in such a manner that it will give accurate measurements of the speed of motor vehicles when properly calibrated and operated by a trained operator or, in the case of the laser SMDs, each of these pieces of equipment is so designed and constructed as to accurately employ measurement techniques based on the velocity of light in such a manner that it will give accurate measurements of the speed of motor vehicles when properly calibrated and operated by a trained operator.
Signature
Dated: _________________________
CERTIFICATE OF DEPARTMENT OF LICENSING CUSTODIAN OF RECORD
I, _____________do certify under penalty of perjury as follows:
I have been appointed by the Director of the Department of Licensing as a legal custodian of driving records of the State of Washington. I certify under penalty of perjury that such records are official and are maintained in the office of the Department of Licensing, Olympia, Washington.
All information contained in this report pertains to the driving record of:
Lic. #___________________
Birthdate:
Name:__________________
Eyes: ____Sex ___
Hgt: ___ Wgt:_____
License Issued:___________
License Expires:___________
After a diligent search of the computer files, the official record indicates that on ______________(date), the following statements apply to the status of the above named person:
The attached document(s) are a true and accurate copy of the document(s) maintained in the office of the Department of Licensing, Olympia, Washington.
(specify all documents attached to this affidavit)
Dated: ______________________
______________________
(name)
Custodian of Records
Place: Olympia, Washington
Date: _______________
Wash. R. Ct. Lim. Juri. CrRLJ 6.13