<p> Department of Labor and Industries Manufactured Home Installer’s Installer Training and Certification Program Monthly Certification Tag Report PO Box 44420, Olympia WA 98504-4420 1-800- 647-0982 Option 5 FAX 360-902-5229 www.FAS.Lni.wa.gov</p><p>Reporting Month Reporting Year Mailing address</p><p>Installer Name Phone</p><p>Manufacturer Coding Work Performed Codes AHI American Homestar ID GUI Guerdon ID PH Palm Harbor CC Concrete Pads/Runners AHO American Homestar OR GUO Guerdon OR RMI Redman ID SC Structural Connections (marriage line, roof cap, CH Champion HB Homebuilders NW RMO Redman OR etc.) FWC Fleetwood CA KA Karston CA SCC Silvercrest CA AS Anchoring System (tie-downs) FWI Fleetwood ID KIT Kit Mfg SCO Silvercrest OR MP Mech./Plumbing (if performed by certified FWO Fleetwood OR LB Liberty SLC Skyline CA installer) FWW Fleetwood WA ML Marlette SLO Skyline OR FS Foundation Support System (footings/piers) FW Fuqua MD Moduline SU Summit CO SV Skirting/Vents/Access GWO Golden West OR NA Nashua VA Valley ER Earthquake Resis. Bracing System Other Enter manufacturer name</p><p>Installer Cert. Tag #: MFR Code: MFR Serial #: Building Jurisdiction: Retailer:</p><p>Work Perf. Codes: Install Date: Owner’s Name: (last) Site Address:</p><p>Installer Cert. Tag #: MFR Code: MFR Serial #: Building Jurisdiction: Retailer:</p><p>Work Perf. Codes: Install Date: Owner’s Name: (last) Site Address:</p><p>Installer Cert. Tag #: MFR Code: MFR Serial #: Building Jurisdiction: Retailer:</p><p>Work Perf. Codes: Install Date: Owner’s Name: (last) Site Address:</p><p>Installer Cert. Tag #: MFR Code: MFR Serial #: Building Jurisdiction: Retailer:</p><p>Work Perf. Codes: Install Date: Owner’s Name: (last) Site Address:</p><p>Reports may be emailed to [email protected] or you may print, sign and mail the report to the address listed at the top of this form. I hereby certify that each installer certification tag used has been properly reported and the information in this report is correct to the best of my knowledge.</p><p>Signature Typed Name (if emailing) Certification Number Date</p><p>F622-078-000 01-2011</p>