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Scale Installation Permit Application Form - State Of Mississippi Department Of Agriculture And Commerce Page 4

Scale test and calibration information (if different from applicant)

Name and address of Licensed Scale Service Repair Company or Service Repairman retained for scale test

___________________________________

__________________________________

Name

Address

Current Mississippi Scale Service Repair #

Test Weight Calibration Certificate #

Certified laboratory which issued calibration certificate

I understand that 1) only a scale service-repair company or scale service repairmen licensed by the Weights and

Measures Division, Mississippi Department of Agriculture and Commerce may test and calibrate a scale following

installation: 2) scale installation and testing must meet applicable requirements of NIST Handbook 44, and

Mississippi Weights and Measures Laws and Regulations; and 3) scale and scale foundation blueprints and

specifications must be supplied to the Director of Weights and Measures.

The undersigned applicant hereby certifies that all statements and information contained herein and schedules

attached hereto are true and correct.

This the

day of

, 20

________________________________________

____________________________________

Signature of Applicant

Title

NOTE:

A Check or money order in the amount of fifty dollars ($50.00) payable to the

MDAC/Weights and Measures and scale foundation blueprints and specifications must

accompany this application. After approval of application and the scale installation inspection

by the Mississippi Department of Agriculture and Commerce Weights and Measures Division a

scale installation permit will be issued.

Official Use Only

Date of Inspection: ___________________________________

Scale Approved

Scale Disapproved

Reason for scale disapproval: ____________________________________________________________

____________________________________________________________________________________

Inspector Name: _________________________________________________

Scale Installation Permit Application Form - State Of Mississippi Department Of Agriculture And Commerce Page 4