Form FDACS-03434 "Affidavit of Annual Inspection for Exempt Facilities" - Florida

What Is Form FDACS-03434?

This is a legal form that was released by the Florida Department of Agriculture and Consumer Services - a government authority operating within Florida. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on July 1, 2020;
  • The latest edition provided by the Florida Department of Agriculture and Consumer Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form FDACS-03434 by clicking the link below or browse more documents and templates provided by the Florida Department of Agriculture and Consumer Services.

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Download Form FDACS-03434 "Affidavit of Annual Inspection for Exempt Facilities" - Florida

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Florida Department of Agriculture and Consumer Services
Division of Consumer Services/Bureau of Fair Rides Inspection
AFFIDAVIT OF ANNUAL INSPECTION FOR EXEMPT FACILITIES
Section 616.242(11), Florida Statutes
Rule 5J-18.0012, Florida Administrative Code
NICOLE “NIKKI” FRIED
Phone: 1-800-435-7352; Fax: (850) 410-3797
COMMISSIONER
FairRides@FDACS.gov
AMUSEMENT COMPANY
STATE OF
COUNTY OF
Before me, the undersigned authority, personally appeared
, and being duly
sworn, states as follows:
1.
The affiant certifies, on the date indicated, that all of the amusement rides listed are in general conformance with
the requirements of Section 616.242(4)(a), Florida Statutes, and Rule 5J-18.0011, Florida Administrative Code.
2.
The affiant is an authorized inspector for the above amusement company and certifies that each amusement ride
has undergone at least a visual nondestructive test for metal fatigue, conducted by a Level ll or Level lll
technician, unless exempt from nondestructive testing by Section 616.242(7)(d), Florida Statutes, and;
a.
All nondestructive tests are current.
b.
All nondestructive tests required or recommended by the manufacturer were conducted.
c.
Each amusement ride has received at least a visual nondestructive test, and that visual nondestructive
test is adequate for the amusement ride to be in general conformance with the requirements of Section
616.242(7), Florida Statutes, and Subsection 5J-18.004(2), Florida Administrative Code.
d.
For those amusement devices for which the manufacturer has not required or recommended a visual
nondestructive test, affiant has designated the required non-destructive test, the component area and
frequency of testing of the component to be tested.
Amusement Ride Name
Amusement Ride Serial No.
1
2
3
4
5
6
7
8
FDACS-03434 Rev. 07/20
Page 1 of 2
Florida Department of Agriculture and Consumer Services
Division of Consumer Services/Bureau of Fair Rides Inspection
AFFIDAVIT OF ANNUAL INSPECTION FOR EXEMPT FACILITIES
Section 616.242(11), Florida Statutes
Rule 5J-18.0012, Florida Administrative Code
NICOLE “NIKKI” FRIED
Phone: 1-800-435-7352; Fax: (850) 410-3797
COMMISSIONER
FairRides@FDACS.gov
AMUSEMENT COMPANY
STATE OF
COUNTY OF
Before me, the undersigned authority, personally appeared
, and being duly
sworn, states as follows:
1.
The affiant certifies, on the date indicated, that all of the amusement rides listed are in general conformance with
the requirements of Section 616.242(4)(a), Florida Statutes, and Rule 5J-18.0011, Florida Administrative Code.
2.
The affiant is an authorized inspector for the above amusement company and certifies that each amusement ride
has undergone at least a visual nondestructive test for metal fatigue, conducted by a Level ll or Level lll
technician, unless exempt from nondestructive testing by Section 616.242(7)(d), Florida Statutes, and;
a.
All nondestructive tests are current.
b.
All nondestructive tests required or recommended by the manufacturer were conducted.
c.
Each amusement ride has received at least a visual nondestructive test, and that visual nondestructive
test is adequate for the amusement ride to be in general conformance with the requirements of Section
616.242(7), Florida Statutes, and Subsection 5J-18.004(2), Florida Administrative Code.
d.
For those amusement devices for which the manufacturer has not required or recommended a visual
nondestructive test, affiant has designated the required non-destructive test, the component area and
frequency of testing of the component to be tested.
Amusement Ride Name
Amusement Ride Serial No.
1
2
3
4
5
6
7
8
FDACS-03434 Rev. 07/20
Page 1 of 2
Amusement Ride Name
Amusement Ride Serial No.
9
10
11
12
13
14
15
16
17
19
20
21
22
23
24
25
26
27
29
30
Engineer's Seal if Engineer
SIGNATURE OF AFFIANT
Sworn to (or affirmed) and subscribed before me by means of ____ physical presence or ___ online notarization, this
_____ day of _________________, 20_____, by _________________________________. Personally known ____,
OR Produced Identification ____. Type of Identification Produced________________________________________.
NOTARY PUBLIC
My commission expires:
FDACS-03434 Rev. 07/20
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