Form FDACS-03017 "Placed in Service Report" - Florida

What Is Form FDACS-03017?

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 May 1, 2017;
  • 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-03017 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-03017 "Placed in Service Report" - Florida

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Florida Department of Agriculture and Consumer Services
Division of Consumer Services, Bureau of Standards
PLACED IN SERVICE REPORT
Sections 525.07 and 531.41, Florida Statutes
Rule 5J-22.003, Florida Administrative Code
ADAM H. PUTNAM
COMMISSIONER
3125 Conner Bld., Lab #2, MS L-2, Tallahassee, FL 32399-1650
Phone (850) 921-1545 Fax (850) 921-1548
Email Address: flwm@freshfromflorida.com
SCALES AND OTHER DEVICES
PETROLEUM
Out Of Service Device
New Installation
Other Devices Restored
(Return To Service Device)
BUSINESS NAME
PHONE NUMBER
DATE OF SERVICE
MAILING ADDRESS
COUNTY
CITY
STATE
ZIP
PHYSICAL LOCATION OF DEVICE IF DIFFERENT THAN ABOVE
ADDRESS/LOCATION
Phone Number
COUNTY
CITY
CONTACT PERSON
DEVICE
DESCRIPTION
DEVICE MANUFACTURER
MODEL NUMBER
SERIAL NUMBER
NTEP NUMBER
CAPACITY
COMMENTS/COC
SERVICE AGENCY INFORMATION
AGENCY NAME
REGISTRATION NUMBER
ADDRESS
CITY
STATE
ZIP
PHONE
By signing, I certify that the device(s) listed above was/were installed and/or calibrated to applicable tolerances as set forth in NIST Handbook
44, as adopted by department rule, utilizing procedures as outlined in said publication and as adopted by rule. I also verify that the standards
used in such testing and calibrations hold a valid certification and are traceable to NIST standards, as required by NIST Handbook 130 and
adopted in department rule. I verify that I have physically sealed all adjustment mechanisms capable of being physically sealed, as required
by department rule. I understand that I must fax, mail or e-mail this form to the department within twenty-four (24) hours of, but not more than
10 days prior to placing or returning listed device(s) into commercial service.
INITIALS {AS SHOWN ON SEAL}
NAME OF SERVICE AGENT (PRINT)
SIGNATURE OF SERVICE AGENT
FDACS-03017 Rev. 05/17
Florida Department of Agriculture and Consumer Services
Division of Consumer Services, Bureau of Standards
PLACED IN SERVICE REPORT
Sections 525.07 and 531.41, Florida Statutes
Rule 5J-22.003, Florida Administrative Code
ADAM H. PUTNAM
COMMISSIONER
3125 Conner Bld., Lab #2, MS L-2, Tallahassee, FL 32399-1650
Phone (850) 921-1545 Fax (850) 921-1548
Email Address: flwm@freshfromflorida.com
SCALES AND OTHER DEVICES
PETROLEUM
Out Of Service Device
New Installation
Other Devices Restored
(Return To Service Device)
BUSINESS NAME
PHONE NUMBER
DATE OF SERVICE
MAILING ADDRESS
COUNTY
CITY
STATE
ZIP
PHYSICAL LOCATION OF DEVICE IF DIFFERENT THAN ABOVE
ADDRESS/LOCATION
Phone Number
COUNTY
CITY
CONTACT PERSON
DEVICE
DESCRIPTION
DEVICE MANUFACTURER
MODEL NUMBER
SERIAL NUMBER
NTEP NUMBER
CAPACITY
COMMENTS/COC
SERVICE AGENCY INFORMATION
AGENCY NAME
REGISTRATION NUMBER
ADDRESS
CITY
STATE
ZIP
PHONE
By signing, I certify that the device(s) listed above was/were installed and/or calibrated to applicable tolerances as set forth in NIST Handbook
44, as adopted by department rule, utilizing procedures as outlined in said publication and as adopted by rule. I also verify that the standards
used in such testing and calibrations hold a valid certification and are traceable to NIST standards, as required by NIST Handbook 130 and
adopted in department rule. I verify that I have physically sealed all adjustment mechanisms capable of being physically sealed, as required
by department rule. I understand that I must fax, mail or e-mail this form to the department within twenty-four (24) hours of, but not more than
10 days prior to placing or returning listed device(s) into commercial service.
INITIALS {AS SHOWN ON SEAL}
NAME OF SERVICE AGENT (PRINT)
SIGNATURE OF SERVICE AGENT
FDACS-03017 Rev. 05/17