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

Form FDACS-03434 or the "Affidavit Of Annual Inspection For Exempt Facilities" is a form issued by the Florida Department of Agriculture and Consumer Services.

The form was last revised in February 1, 2017 and is available for digital filing. Download an up-to-date Form FDACS-03434 in PDF-format down below or look it up on the Florida Department of Agriculture and Consumer Services Forms website.

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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(10), Florida Statutes
Rule 5J-18.0012, Florida Administrative Code
ADAM H. PUTNAM
COMMISSIONER
Phone: 1-800-435-7352; Fax: (850) 410-3797
FairRides@FreshFromFlorida.com
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(6)(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(6), 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. 02/17
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(10), Florida Statutes
Rule 5J-18.0012, Florida Administrative Code
ADAM H. PUTNAM
COMMISSIONER
Phone: 1-800-435-7352; Fax: (850) 410-3797
FairRides@FreshFromFlorida.com
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(6)(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(6), 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. 02/17
Page 1 of 2
Amusement Ride Name
Amusement Ride Serial No.
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
Engineer's Seal if Engineer
SIGNATURE OF AFFIANT
Subscribed and sworn to before me this ________ day of _____________________, 20_____, by
________________________ personally known ____, or who produced identification ____. Type of identification
produced ___________________________________________________________________________________.
NOTARY PUBLIC
My commission expires:
FDACS-03434 Rev. 02/17
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