GAMBLING VESSEL REGISTRATION FORM PART I INSTRUCTIONS (1) The owner or operator of each gambling vessel intending to operate in coastal waters of the State shall complete and submit this form and the appropriate registration fee as established in Rule 62-606.400(5), F.A.C., to the Department as established below. Gambling vessel registration shall be based on the calendar year and valid only for that calendar year. (a) For gambling vessels operating in coastal waters on April 4, 2010 the initial form and fee shall be submitted within 60 days after April 4, 2010. (b) For gambling vessels beginning operations in coastal waters after April 4, 2010, the initial form and fee shall be submitted at least 30 days prior to the vessel entering coastal waters. (c) The annual renewal form and fee shall be submitted 30 days prior to expiration of the gambling vessel s registration. You should familiarize yourself with Chapter 62-606, F.A.C., before completing this form. (2) One copy of the form (including all attachments) and the registration fee shall be submitted to: Florida Department of Environmental Protection Domestic Wastewater Section Mail Station 3540 2600 Blair Stone Road Tallahassee, Florida 32399-2400 Checks shall be made payable to the Florida Department of Environmental Protection. A registration application will not be processed until the registration fee has been received. (3) The registration fee for this gambling vessel shall be calculated as follows: Registration Fee = $17.35 x (Total Persons Allowed) (4) Note, the owner and operator of a gambling vessel are responsible for complying with all of the provisions of Chapter 62-606, F.A.C. If the conditions of the Chapter are violated, the owner or operator is subject to penalties in accordance with Section 376.25, F.S., and other Department rules. Page 1 of 5
PART II - GENERAL INFORMATION (1) Calendar Year (January 1 through December 31): (2) Gambling Vessel Owner Business Name: Postal Address: E-mail: Phone: Facsimile: (3) Gambling Vessel Operator (if different from gambling vessel owner) Business Name: Postal Address: E-mail: Phone: (4) Agent for Service of Process Facsimile: (Provide the registered agent for each business identified in Part II, paragraphs (2) and (3) above.) Registered agent for Gambling Vessel Owner s business Name: Address: Registered agent for Gambling Vessel Operator s business Name: Address: Page 2 of 5
PART III GAMBLING VESSEL INFORMATION (1) Gambling Vessel Identification and Capacity Vessel Call Sign: Hull Identification No.: Port of Registry: Berth Address: Passenger Capacity: Crew Capacity: Total Persons Allowed: Gross Register Tonnage (GRT): (2) Gambling Vessel Weekly Voyage Schedule Net Register Tonnage (NRT): Day of week Monday Tuesday Wednesday Thursday Friday Saturday Sunday Time Schedule when Passengers are Onboard (3) Gambling Vessel Waste Management Systems Description Provide a description of all waste management systems (including systems for the treatment, storage, or disposal of waste for the gambling vessel identified in this form) including, but not limited to, system type, design, operation, location, and capacity of all discharge pipes and valves, and the number and capacity of all storage areas and holding tanks. These data should be summarized in a waste management process flow diagram. Use additional sheets if needed. Total treatment and holding capacities: Additional information: (gallons per minute) (gallons) Page 3 of 5
PART IV STATEMENT BY WATERFRONT-LANDING FACILITY OWNER The undersigned owner of the waterfront-landing facility or designated representative that is registered as the gambling vessel s berth location certifies that procedures for the release of waste from the gambling vessel are established and that a waste-management service that has the capability of handling and disposing of the facility s minimum waste-service is available. Signature of Waterfront-Landing Facility Owner or Designated Representative Date Name and Title Page 4 of 5
PART V - STATEMENT BY GAMBLING VESSEL OWNER REGISTRATION MUST BE EXECUTED UNDER OATH PURSUANT TO SECTION 376.25(3)(b), FLORIDA STATUTES The undersigned gambling vessel owner, operator, or designated representative swears that the statements made in this notice are true and complete to the best of his knowledge and belief. The undersigned agrees to comply fully with the provisions of Chapter 62-606, F.A.C., and to advise the Department within 15 days of any change in the information required in Rule 62-606.400, F.A.C., during the period that a registration is valid. The undersigned agrees to retain an Agent for Service of Process consisting of an individual resident of the State, a domestic corporation, or a foreign corporation having a place of business in and authorized to do business in Florida. The undersigned also agrees that the Florida Department of Environmental Protection may inspect the gambling vessel and berth location during business hours to ensure compliance with Chapter 62-606, F.A.C. In WITNESS WHEREOF, the undersigned has executed this statement, Signature of Gambling Vessel Owner, Operator, or Designated Representative, Date Name and Title Before me, the undersigned authority, personally appeared who was sworn and the foregoing statement was acknowledged before me this day of, 20. He/she is personally known to me or has produced as identification. Notary Public Signature [Notary Seal] Print Notary Name Commission Expiration: Commission Number: Page 5 of 5