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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