07-323-001/
i Department of Environmental
i Resources Management
MIAMI-
AFFIDAVIT FOR ASBESTOS SURVEY /NOTICE Division of Air Quality
OF ASBESTOS RENOVATION OR DEMOLITION Management
� 1 ��' Area &Mobile Sources Section
33 S.W. 2nd Avenue, Suite 9 -223
Miami, FL 33130 -1540
1. Project Type: !� j' � �05� �- � �)
j yp ❑ Demolition ,� ation El Process # Folio: �o
2. Project Name on, 41) l %� l `7 i
Address 4 t i J( 1 6n �— /•
City ��.'? 1 f i iii, (l ., , State i— Zip Code " - 2 -----;' County l:) I=—
3. Project Dates (mm/dd/yy): Start_,---! r` / % Finish
4. Contractor 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 area in
square feet that will be impacted by the project)
To (I�') ?1 }f
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 40 CFR 61, subpart M, section 145(a) 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 40 CFR 61, subpart M, section 145(a) 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(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 violations of the above referenced regulations may result in civil or criminal prosecution or both at penalties
and fines of up to $25,000 per day per violation.
r ('r
Name-in Print (Owner, Lessee or Authorized Rep tesentative)/Titlp, ,r t; Address (Owner, Lessee or Authorized Rep.)
Signature (Owner, Lessee or Authorized Representative
with Notarized Authorization Letter)
Telephone Number
STATE OF FLORIDA )
COUNTY OF DADE ) ss:
The foregoing instrument was acknowledged before me this day of ?f / , 200_ by
=' who has produced, as identification and who did (did ,n q take an oath.
-� (: i• .� -�,` � { •`'. - .41..E -�--' ' ), 1 ,'i � s'
Notary Public, State of Florida at, Large
Received by Name of DERM'Pe- rsonnel /Section ' Dyed Sioatur)& ►=
THIS IS NOT A NESHAP NOTIFICATION —A SEPARATE NOTIFICATION MUST BE
SUBMITTED FOR RENOVATION OR DEMOLITION
161.01 -154 6/06 See Reverse Side for Additional Information