Form DH4105 "Application for Master Septic Tank Contractor Registration" - Florida

What Is Form DH4105?

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 October 1, 1996;
  • 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;
  • Fill out the form in our online filing application.

Download a printable version of Form DH4105 by clicking the link below or browse more documents and templates provided by the Florida Department of Health.

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Download Form DH4105 "Application for Master Septic Tank Contractor Registration" - Florida

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STATE OF FLORIDA
DEPARTMENT OF HEALTH
APPLICATION FOR
MASTER SEPTIC TANK CONTRACTOR REGISTRATION
FORWARD COMPLETED APPLICATION WITH ALL REQUIRED DOCUMENTATION AND $75.00 FEE TO:
DEPARTMENT OF HEALTH, BUREAU OF ENVIRONMENTAL HEALTH,
4052 BALD CYPRESS WAY, BIN# A08, TALLAHASSEE, FL 32399-1710.
COMPLETED APPLICATION MUST BE RECEIVED 21 DAYS PRIOR TO EXAMINATION DATE.
SECTION I: PERSONAL INFORMATION
NAME OF APPLICANT:
LAST
FIRST
MI
DATE OF BIRTH:
EMAIL ADDRESS:
MM / DD / YY
BUSINESS NAME
TELEPHONE (
)
MAILING ADDRESS
STREET / PO BOX
CITY
ST
ZIP CODE
REGISTRATION SR
AUTHORIZATION SA
SECTION II: TRAINING CERTIFICATION [ATTACH COPIES OF TRAINING CERTIFICATES]
COURSE TITLE
LOCATION
DATE
SECTION III: MORAL CHARACTER
PLEASE ANSWER EACH QUESTION. IF YOU ANSWER YES TO ANY QUESTION PLEASE
YES
NO
ATTACH A NOTARIZED STATEMENT EXPLAINING YOUR ANSWER.
HAS THE DEPARTMENT IMPOSED PROBATION OR SUSPENSION ON YOUR SEPTIC TANK
CONTRACTOR REGISTRATION DURING THE LAST THREE YEARS?
HAVE YOU BEEN ASSESSED MORE THAN $500.00 IN ADMINISTRATIVE PENALTIES BY THE
DEPARTMENT IN THE LAST THREE YEARS?
DO YOU HAVE AN OUTSTANDING FINE ASSESSED PURSUANT TO CHAPTER 64E-6, FAC,
WHICH IS IN FINAL ORDER STATUS AND JUDICIAL REVIEWS ARE EXHAUSTED?
HAVE YOU SUCCESSFULLY RESOLVED ANY DISCIPLINARY ACTION INVOLVING SEPTIC
TANK CONTRACTING WHERE AN ADMINISTRATIVE ACTION HAS BEEN FILED?
HAVE YOU HAD A MASTER SEPTIC TANK CONTRACTOR REGISTRATION REVOKED BY THE
DEPARTMENT IN THE LAST THREE YEARS?
I AFFIRM THAT THE INFORMATION CONTAINED IN THIS APPLICATION, WHICH SERVES AS THE BASIS FOR
DETERMINING MY ELIGIBILITY FOR MASTER SEPTIC TANK CONTRACTOR REGISTRATION, IS TRUE.
I
UNDERSTAND ANY MISREPRESENTATION OR CONCEALMENT OF MATERIAL FACTS IN THIS APPLICATION IS
GROUNDS FOR ADMINISTRATIVE FINES, DENIAL OR REVOCATION OF MY REGISTRATION.
APPLICANT’S SIGNATURE
DATE
CONTINUED ON REVERSE
DH 4105, 10/96 Incorporated: 64E-6.020, FAC
STATE OF FLORIDA
DEPARTMENT OF HEALTH
APPLICATION FOR
MASTER SEPTIC TANK CONTRACTOR REGISTRATION
FORWARD COMPLETED APPLICATION WITH ALL REQUIRED DOCUMENTATION AND $75.00 FEE TO:
DEPARTMENT OF HEALTH, BUREAU OF ENVIRONMENTAL HEALTH,
4052 BALD CYPRESS WAY, BIN# A08, TALLAHASSEE, FL 32399-1710.
COMPLETED APPLICATION MUST BE RECEIVED 21 DAYS PRIOR TO EXAMINATION DATE.
SECTION I: PERSONAL INFORMATION
NAME OF APPLICANT:
LAST
FIRST
MI
DATE OF BIRTH:
EMAIL ADDRESS:
MM / DD / YY
BUSINESS NAME
TELEPHONE (
)
MAILING ADDRESS
STREET / PO BOX
CITY
ST
ZIP CODE
REGISTRATION SR
AUTHORIZATION SA
SECTION II: TRAINING CERTIFICATION [ATTACH COPIES OF TRAINING CERTIFICATES]
COURSE TITLE
LOCATION
DATE
SECTION III: MORAL CHARACTER
PLEASE ANSWER EACH QUESTION. IF YOU ANSWER YES TO ANY QUESTION PLEASE
YES
NO
ATTACH A NOTARIZED STATEMENT EXPLAINING YOUR ANSWER.
HAS THE DEPARTMENT IMPOSED PROBATION OR SUSPENSION ON YOUR SEPTIC TANK
CONTRACTOR REGISTRATION DURING THE LAST THREE YEARS?
HAVE YOU BEEN ASSESSED MORE THAN $500.00 IN ADMINISTRATIVE PENALTIES BY THE
DEPARTMENT IN THE LAST THREE YEARS?
DO YOU HAVE AN OUTSTANDING FINE ASSESSED PURSUANT TO CHAPTER 64E-6, FAC,
WHICH IS IN FINAL ORDER STATUS AND JUDICIAL REVIEWS ARE EXHAUSTED?
HAVE YOU SUCCESSFULLY RESOLVED ANY DISCIPLINARY ACTION INVOLVING SEPTIC
TANK CONTRACTING WHERE AN ADMINISTRATIVE ACTION HAS BEEN FILED?
HAVE YOU HAD A MASTER SEPTIC TANK CONTRACTOR REGISTRATION REVOKED BY THE
DEPARTMENT IN THE LAST THREE YEARS?
I AFFIRM THAT THE INFORMATION CONTAINED IN THIS APPLICATION, WHICH SERVES AS THE BASIS FOR
DETERMINING MY ELIGIBILITY FOR MASTER SEPTIC TANK CONTRACTOR REGISTRATION, IS TRUE.
I
UNDERSTAND ANY MISREPRESENTATION OR CONCEALMENT OF MATERIAL FACTS IN THIS APPLICATION IS
GROUNDS FOR ADMINISTRATIVE FINES, DENIAL OR REVOCATION OF MY REGISTRATION.
APPLICANT’S SIGNATURE
DATE
CONTINUED ON REVERSE
DH 4105, 10/96 Incorporated: 64E-6.020, FAC
SECTION IV: COUNTY HEALTH DEPARTMENT REVIEW:
PLEASE ANSWER EACH QUESTION. IF YOU ANSWER “YES” TO ANY QUESTION PLEASE
YES
NO
ATTACH A STATEMENT AND DOCUMENTATION EXPLAINING YOUR ANSWER.
HAS THE DEPARTMENT IMPOSED PROBATION OR SUSPENSION ON THIS APPLICANT’S
SEPTIC TANK CONTRACTOR REGISTRATION DURING THE LAST THREE YEARS?
HAS THIS APPLICANT BEEN ASSESSED MORE THAN $500.00 IN ADMINISTRATIVE PENALTIES
BY THE DEPARTMENT IN THE LAST THREE YEARS?
DO YOU HAVE AN OUTSTANDING FINE ASSESSED AGAINST THIS CONTRACTOR WHICH IS IN
FINAL ORDER STATUS AND JUDICIAL REVIEWS ARE EXHAUSTED?
HAS THIS CONTRACTOR SUCCESSFULLY RESOLVED ANY DISCIPLINARY ACTION
INVOLVING SEPTIC TANK CONTRACTING WHERE ADMINISTRATIVE ACTION WAS FILED?
HAS THIS APPLICANT HAD A MASTER SEPTIC TANK CONTRACTOR REGISTRATION
REVOKED BY THE DEPARTMENT IN THE LAST THREE YEARS?
REVIEWED BY
TITLE
COUNTY
DATE
STATE HEALTH OFFICE REVIEW:
Application Check No.
FOR
Registration Check No. ____________
Date of Application Check:
HSES
Date of Registration Check _________
Check Amount:
OFFICE
Check Amount ___________________
Date of Approval/Denial:_______________
USE
Registration Number ______________
Approved By
_____________________
ONLY
Date Issued _____________________
Examination Date _____________________
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