Fdacs-03320 Application Form For Registration Of Service Agencies - Florida Department Of Agriculture And Consumer Services, Division Of Consumer Services, Bureau Of Standards
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1Florida Department of Agriculture and Consumer Services
Division of Consumer Services, Bureau of Standards
APPLICATION FOR REGISTRATION OF
SERVICE AGENCIES
ADAM H. PUTNAM
COMMISSIONER
Section 525.07, Florida Statutes
Rule 5J-21.005, Florida Administrative Code
Under the provisions of s. 525.07(8)(a), F.S., the undersigned hereby registers with the Florida Department of Agriculture and
Consumer Services as a service agency for the purpose of repairing and/or installing petroleum fuel measuring devices in the State
of Florida. Further, the undersigned acknowledges that under the provisions of s. 525.07(9), F.S., any test measures used to adjust
the accuracy of any petroleum fuel measuring device in this state must be calibrated with standards traceable to the National
Institute of Technology and Standards (NIST) within one (1) year prior to the date of the adjustment for test measure volumes of less
than 500 gallons and within three (3) years before the date of adjustment for test measure volumes of 500 gallons or more.
Company _________________________
Phone (___) _____________________
Address
_________________________
State
______________
City
_________________________
ZIP
______________
Contact
_________________________
________________________________
Title
Email
_________________________
I understand according to the provisions of Chapter 525, Florida Statutes, and the rules adopted pursuant
to this Chapter, that if the Department should find a measuring device placed in service by this service
agency that does not comply with the aforementioned referenced provisions, the device may be taken out
of service and the service agency may be subject to penalties as provided by law. I also understand that
the Department may in addition suspend or revoke any such registration issued under this section for
violations of these laws and rules adopted pursuant to Chapter 525, Florida Statutes.
Company ________________________________
_________________________
Please Print Name
Title
Signature ________________________________
Date _____________________
Please direct phone calls to (850) 921-1545, and faxes to (850) 921-1548.
Please return completed form to:
Florida Department of Agriculture and Consumer Services
Division of Consumer Services, Bureau of Standards
3125 Conner Blvd., Bldg. #2, MS L-2
Tallahassee, FL 32399-1650
Department Staff Only: Company Name Verified with the Department of State?
Yes
Initials _______
FDACS-03320 Rev. 12/12
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