11-1243-001,�•. ,;:: f � ,�nM p ,:�'� ,;° .a�1.. ski::= r ��.. _ -J �, . W.w� a.r;r; �
✓r r / ! Department of Environmental Y L
Resources Management
AFFIDAVIT FOR ASBES
OS SURVEY/NOTICE Air Quality Management Division
MIAMI-
AFFIDAVIT RENOVATION Air Facilities Section
OF DEMOLITION OR AS�'' 701 N.w.1st Court, 2nd Floor
® Miami, FL 33136
a SECTION N
,. , ❑ Roofing Process #�_°,J 17,000 FoIio:
a. Project Type: ❑ molition � , M/ Renovation
MAC",( e jC," /, �V Address i' � 7,(t ""'
b. Project Name � :�'rJ ✓/ "Ei'%:�'c�
City j R,1 i.A I State- :_ zip Code County
C. Project Dates (mm /dd /yy): Start E �� � -- Finish
d. Contractor d f % e,�IIV5 l 4a l_.t`l 111 - 1� Florida License # G'ejr P' /S-Z)
T M� /
e. Contractor Address !�� fAs 104 1 . Con tractorTelephone f i0 , _e � 41(a
t
f. Give a brief description of work to be done at the above mentioned address: (include scope of work and the estimated area in
square feet that willabe impacted by the project)
-: f�'✓1 ► �1 t r41 r (fW S
�} t
SECTION II
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. fy
-2-. Pursuant to 40 CFR 6 -I, subpart M, section 145(a) and 469.001 -015 Florida Statutes, all regula asa,0410N terials
(RACM) must be removed prior to any renovation activity that may impact the RACM-at the above referenced property.
3. Pursuant to 40 CFR 61, subpart M, section '145(a) and 469.00`1 -015 Florida Statutes, all regulated asbestos containing materials
(RACNI).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(a) 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 the demolition of two or more single family residences, located at the same property, adjacent properties or
non- adjacent properties that are being demolished for a common purpose not specifically exempted from the above regulations, is subject to
the same regulations (e.g., for c'tommercial or other non- exempt facilities). I am also aware that violations of the above- referenced regulations
may result in civil or criminal p osecution or both and penalties and fines of up to $25,000 per day per violation.
Name in Print (Owner, Lessee or Authorized Representat" e)/Title Address (Owner, Lessee or Authorized Rep.) "
4a. q }
Signature (Owner, Lessee or Authorized Representative Telelphone Number
with Notarized Authorization Letter)
STATE OF FLORIDA )
'COUNTY OF DADE ) ss
The foregoing instrument was acknowledged before me this day of 4 `'moat' 200'_ by
I
u, r '//°�� . ` who has produced, as identification and who did (did not) take an oath.
Notary Public, State of Florida at' Large
Hutivt� Ap6vt fNa/1164W ___F// A4
{ Received by Name of DERM;R rsonnel /Section r- Dated Signature T
THIS IS NOT A NESHAP NOTIFICATION —A SEPARATE NOTIFICATION UST 13E
SUBMITTED FOR RENOVATION OR DEMOLITION
161.01 -154 4/10 See Reverse Side for Additional Information