Form DH4076 "Application for Septic Tank Contractor Registration Renewal" - Florida

Form DH4076 is a Florida Department of Health form also known as the "Application For Septic Tank Contractor Registration Renewal". The latest edition of the form was released in January 1, 2003 and is available for digital filing.

Download a PDF version of the Form DH4076 down below or find it on Florida Department of Health Forms website.

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Download Form DH4076 "Application for Septic Tank Contractor Registration Renewal" - Florida

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STATE OF FLORIDA
DEPARTMENT OF HEALTH
APPLICATION FOR SEPTIC TANK CONTRACTOR
REGISTRATION RENEWAL
FORWARD COMPLETED APPLICATION, PASSPORT STYLE PHOTO
MAKE CORRECTIONS IN THE SPACES BELOW.
(REQUIRED EVERY 5 YEARS STARTING WITH THE 2004 RENEWAL
NOTIFY THE BUREAU OF ENVIRONMENTAL
CYCLE), AND $100.00 FEE TO: FLORIDA DEPT OF HEALTH, BUREAU
.
HEALTH WITHIN 30 DAYS OF ANY CHANGES
OF ENVIRONMENTAL HEALTH, 4052 BALD CYPRESS WAY, BIN# A08,
TALLAHASSEE, FL 32399-1710
NEW PHOTOGRAPHS ARE
REQUIRED FOR 2014 RENEWAL
APPLICATION FOR [ ] REGISTERED [ ] MASTER SEPTIC TANK CONTRACTOR RENEWAL
NAME
MAILING
ADDRESS
BUSINESS
NAME
COUNTY
TELEPHONE
FAX
EMAIL
CONTINUING EDUCATION: ATTACH A COPY OF CERTIFICATE OF ATTENDANCE. LIST MASTER CONTRACTOR
LEVEL COURSES FIRST AND CHECK “ML” FOR MASTER LEVEL COURSES.
COURSE TITLE
LOCATION
DATE
ML
I AFFIRM THE INFORMATION CONTAINED IN THIS APPLICATION, WHICH SERVES AS THE BASIS FOR
DETERMINING MY ELIGIBILITY FOR REGISTRATION RENEWAL, IS TRUE. I UNDERSTAND ANY
MISREPRESENTATION OR CONCEALMENT OF MATERIAL FACTS IN THIS APPLICATION IS GROUNDS FOR AN
ADMINISTRATIVE FINE OR DENIAL OR REVOCATION OF MY SEPTIC TANK CONTRACTOR REGISTRATION.
APPLICANT’S SIGNATURE
DATE ___________________________
FOR
Application Check No.
Registration Number:
DCEH
Date of Application Check:
Check Amount:
Date Issued:
OFFICE
Date of Approval:______________________
USE
or
Date of Denial: _______________________
ONLY
DH 4076, 01/03 (Obsoletes All Previous Editions) Incorporated: 64E-6.020, FAC
STATE OF FLORIDA
DEPARTMENT OF HEALTH
APPLICATION FOR SEPTIC TANK CONTRACTOR
REGISTRATION RENEWAL
FORWARD COMPLETED APPLICATION, PASSPORT STYLE PHOTO
MAKE CORRECTIONS IN THE SPACES BELOW.
(REQUIRED EVERY 5 YEARS STARTING WITH THE 2004 RENEWAL
NOTIFY THE BUREAU OF ENVIRONMENTAL
CYCLE), AND $100.00 FEE TO: FLORIDA DEPT OF HEALTH, BUREAU
.
HEALTH WITHIN 30 DAYS OF ANY CHANGES
OF ENVIRONMENTAL HEALTH, 4052 BALD CYPRESS WAY, BIN# A08,
TALLAHASSEE, FL 32399-1710
NEW PHOTOGRAPHS ARE
REQUIRED FOR 2014 RENEWAL
APPLICATION FOR [ ] REGISTERED [ ] MASTER SEPTIC TANK CONTRACTOR RENEWAL
NAME
MAILING
ADDRESS
BUSINESS
NAME
COUNTY
TELEPHONE
FAX
EMAIL
CONTINUING EDUCATION: ATTACH A COPY OF CERTIFICATE OF ATTENDANCE. LIST MASTER CONTRACTOR
LEVEL COURSES FIRST AND CHECK “ML” FOR MASTER LEVEL COURSES.
COURSE TITLE
LOCATION
DATE
ML
I AFFIRM THE INFORMATION CONTAINED IN THIS APPLICATION, WHICH SERVES AS THE BASIS FOR
DETERMINING MY ELIGIBILITY FOR REGISTRATION RENEWAL, IS TRUE. I UNDERSTAND ANY
MISREPRESENTATION OR CONCEALMENT OF MATERIAL FACTS IN THIS APPLICATION IS GROUNDS FOR AN
ADMINISTRATIVE FINE OR DENIAL OR REVOCATION OF MY SEPTIC TANK CONTRACTOR REGISTRATION.
APPLICANT’S SIGNATURE
DATE ___________________________
FOR
Application Check No.
Registration Number:
DCEH
Date of Application Check:
Check Amount:
Date Issued:
OFFICE
Date of Approval:______________________
USE
or
Date of Denial: _______________________
ONLY
DH 4076, 01/03 (Obsoletes All Previous Editions) Incorporated: 64E-6.020, FAC
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