"Temporarily Installed Component
This certified component has been assembled, installed, adjusted, and tested by me according to the instructions provided by the manufacturer.
Signature
Company Name
Street Address, P.O. Box
City, State, Zip Code
Date of Installation"
The replacement of the temporarily installed component by a component other than the component originally removed for repair shall be reported as specified by subsection (d).
Haw. Code R. § 11-45-27