Company Name and Location information
Name
Company Address
Street Number # Street Name City , FL Zip County Name
Fax and Email information
Under Florida law, e-mail addresses are public records. If you do not want your e-mail address released in response to a public records request, do not send electronic mail to this entity. Instead, contact this office by phone or in writing (F.S. 668.6076).
Phone Fax Email
Owner Name and Contact information
First Name Last Name
Mailing Address (Complete Boxes if different from company address above)
Street Number#: Street Name City State Zip Phone Fax Email
Current Air Quality Testing Company Information
Address City State ,Zip
Phone Number and Fax
Phone Fax
Please indicatate your current testing schedule
Jan/Apr/Jul/Oct Feb/May/Aug/Nov Mar/Jun/Sep/Dec
If testing is not currently being performed, your quarterly schedule will begin with the month following submission of this form.
Shops not open year round only need to submit results for the quarters they are open.
Is Your Shop Open Year Round?
Yes No
If "no," indicate below the months it is open:
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
This form is for your convenience in reporting information required in s. 381.895., F.S. Completed form and all sample results should be sent to: Bureau of Facility Programs, 4052 Bald Cypress Way, Bin A08, Tallahassee, Florida, 32399-1710.
Form DH 4125, 1/00
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This questionnaire was created by Perseus SurveySolutions for the Web.
