Form DH4066 "Application for Maintenance Service Permit" - Florida

What Is Form DH4066?

This is a legal form that was released by the Florida Department of Health - 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 February 1, 2010;
  • The latest edition provided by the Florida Department of Health;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;

Download a printable version of Form DH4066 by clicking the link below or browse more documents and templates provided by the Florida Department of Health.

ADVERTISEMENT
ADVERTISEMENT

Download Form DH4066 "Application for Maintenance Service Permit" - Florida

799 times
Rate (4.5 / 5) 40 votes
STATE OF FLORIDA
DEPARTMENT OF HEALTH
APPLICATION FOR
MAINTENANCE SERVICE PERMIT
Authority: Chapter 381, F.S.
Permit/ Application Number:
Chapter 64E-6, F.A.C.
Date received:
/
/
Fee Paid:
Receipt Number:
Application is hereby made to the DOH
County Health Department, requesting the
issuance of a Maintenance Service Permit for the following business:
Business Name:
Phone:
Business Location:
City:
State:
Zip:
Business Mailing Address (If different from above):
Owner/Agent (Circle One):
Owner/Agent Mailing Address:
City:
State:
Zip:
Description of Geographic Area Serviced from this Location:
List the brands of equipment or components you are authorized to service (Provide a letter from each manufacturer of the unit or
component you will service stating that you are authorized to provide service to that type of unit or component and will be
provided with training, operation and maintenance manuals, service equipment, and spare mechanical parts in order to provide
necessary warranty and maintenance service to their equipment).
Make and Model
Manufacturer
Manufacturer's Address
Number of systems currently under contract
; Number of full-time maintenance service personnel
,
Does your company currently retain a Class D wastewater treatment plant operator to provide service to systems treating more
than 1500 gallons per day? Yes
No
If yes, provide a copy of the operator's certification. Is you company licensed
as a plumbing service or do you possess a septic tank contractor registration or certificate of registration from DOH?
Plumbing Contractor: Yes
No
Qualifying Contractor:
License Number:
Registered Septic Tank Contractor: Yes
No
Qualifying Contractor:
Registration Number:
Authorized Septic Tank Service: Yes
No
Certificate of Authorization Number:
List service and repair equipment available at your facility:
Spare Mechanical Parts
Quantity
Spare Mechanical Parts
Quantity
I am familiar with the requirements of Chapter 64E-6, F.A.C. and understand that I must be in possession of a current maintenance service permit in order to
operate an aerobic treatment unit or performance based treatment system maintenance service. I further understand that a maintenance service permit may be
revoked for failure to comply with the requirements of chapter 64E-6, F.A.C.
/
/
Signature of Owner or Agent
Date
County Health Department Recommendation:
Approve
Disapprove
If disapproved, explain:
Recommendation by:
CHD
Date
/
/
DH 4066, 02/10 (Obsoletes All previous Editions) Incorporated: 64E-6.012, FAC
STATE OF FLORIDA
DEPARTMENT OF HEALTH
APPLICATION FOR
MAINTENANCE SERVICE PERMIT
Authority: Chapter 381, F.S.
Permit/ Application Number:
Chapter 64E-6, F.A.C.
Date received:
/
/
Fee Paid:
Receipt Number:
Application is hereby made to the DOH
County Health Department, requesting the
issuance of a Maintenance Service Permit for the following business:
Business Name:
Phone:
Business Location:
City:
State:
Zip:
Business Mailing Address (If different from above):
Owner/Agent (Circle One):
Owner/Agent Mailing Address:
City:
State:
Zip:
Description of Geographic Area Serviced from this Location:
List the brands of equipment or components you are authorized to service (Provide a letter from each manufacturer of the unit or
component you will service stating that you are authorized to provide service to that type of unit or component and will be
provided with training, operation and maintenance manuals, service equipment, and spare mechanical parts in order to provide
necessary warranty and maintenance service to their equipment).
Make and Model
Manufacturer
Manufacturer's Address
Number of systems currently under contract
; Number of full-time maintenance service personnel
,
Does your company currently retain a Class D wastewater treatment plant operator to provide service to systems treating more
than 1500 gallons per day? Yes
No
If yes, provide a copy of the operator's certification. Is you company licensed
as a plumbing service or do you possess a septic tank contractor registration or certificate of registration from DOH?
Plumbing Contractor: Yes
No
Qualifying Contractor:
License Number:
Registered Septic Tank Contractor: Yes
No
Qualifying Contractor:
Registration Number:
Authorized Septic Tank Service: Yes
No
Certificate of Authorization Number:
List service and repair equipment available at your facility:
Spare Mechanical Parts
Quantity
Spare Mechanical Parts
Quantity
I am familiar with the requirements of Chapter 64E-6, F.A.C. and understand that I must be in possession of a current maintenance service permit in order to
operate an aerobic treatment unit or performance based treatment system maintenance service. I further understand that a maintenance service permit may be
revoked for failure to comply with the requirements of chapter 64E-6, F.A.C.
/
/
Signature of Owner or Agent
Date
County Health Department Recommendation:
Approve
Disapprove
If disapproved, explain:
Recommendation by:
CHD
Date
/
/
DH 4066, 02/10 (Obsoletes All previous Editions) Incorporated: 64E-6.012, FAC