10-649-002MIAMF PCIEM
AFFIDAVIT FOR ASBESTOS SURVEY/NOTICE Air F �baoSec
OF ASBESTOS RENOVATION OR DEMOLITION Miami, FL33130-1540 400
1. Project Type: [ ] Demolition [ x ] Renovation [ ] Roofing Process # Folio: I CA4Q25C�OCf�I
I
2. Project Name Dr. Perez — Hmkhccfe Sp* Address 7000 &V 62M Ave *545
City S. Am! State Zip Code 331 Cougly AM. DaAl- r
3. Project Dates (mm/dd. /yy): Start-48A§k'4914�, Finish
4. ContractorTDD Florida License #
5. Contractor Address Contractor Telephone
6. Give a brief description of work to be done at the above mentioned address: (include scope of work, and the
estimated
r
ea i a feet that will be impacted by the project
a )
I the undersigned hereby attest that I am aware of the following:
1. Pursuant to 40 CFR 61, subpart M, section 145 (a) and 469.001 -015 Florida Statutes an asbestos survey at the above
referenced property may be required prior to any renovation or demolition activity.
2. Pursuant to 40CFR 61, subpart M, section 145 (c) and 469.001 -015 Florida Statutes, all regulated asbestos containing
materials (RACM) must be removed prior to any renovation activity that may impact the RACM at the above referenced
property.
3. Pursuant to 40CFR 61 subpart M, section 145 (c) and 469.001 -015 Florida Statutes, all regulated asbestos containing
materials (RACM) must be removed prior to any demolition activity that impacts the (RACM) at the above referenced
property.
4. Pursuant to 40 CFR 61 subpart M, section 145 (b) and 469.001 -015 Florida Statutes, a written notification must be
submitted to DERM at least 10 working days prior to demolition or asbestos abatement activity at the above referenced
property.
Additionally I am aware that violations of the above referenced regulations may result in civil or criminal prosecution or both or
penalties and fines of up to $25,000 per day per violation.
/l�f'
Name in Print (Own r, Lessee or JAurized Representative) ltle• Address (Owner, Lessee or Authorized Rep.
Signature '(O ne , Lessee or )(ut orized Representative Telephone Number
with Notarize Authorizati tter.)
STATE OF FLORIDA )
COUNTY OF DADE ) ss.: ..- 1
The for ment was acknowledged before me this c z 80h day of '�v/ , 20150 by
W 0 % who has produced, as identification and who did (did not) take an oath..
44�-
orida at Large .�ICII.L.0n1/i6M
MYOMM88 NI00MM
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THIS IS NOT A NESHAP NOTIFICATION — A SEPARATE NOTIFICATION MUST BE
SUBMITTED FOR RENOVATION OR DEMOLITION
See Reverse Side for Additional Information Rev. 12/02