06-138-001F1, R ar ent of Environmental
esources Management
MIAMI•DADE AFFIDAVIT FOR ASBESTOS SURVEY vision of Air Quality
OF ASBESTOS RENOVATION OR DE VA
,. Management
Air Facilities Section
d Avenue, Suite 900
e Miami, FL 33130-1540
i
1. Project Type: ❑ Demolition ❑ Renovation ❑ Roofing Process # Folio:
2. Project Name i) 1 f„I \,AJ?. t 4 i .c Address r`' : %. >��`� j ! s. ( -
City State f 1_ Zip Code , :A ` , County OKI (I
3. Project Dates (mm/dd/yy): Start Finish !
4. Contractor Florida License #
5. Contractor Address Contractor Telephone
4 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)
'.=W 1 t it - 1 1r��\.� r {�tl� i yC'' 1 •r. `..,
I �
1z I, the undersigned, hereby attest that I am aware of the following:
`I. Pursuant to 40 CFR 61, subpart M, section 145(a) and 469.001-015 Florida Statutes, an asbestos survey at the above referenced
i property may be required prior to any renovation or demolition activity.
i'
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. g
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.
i%
_ Q
Name in Print (Owner,' Lessee or Authorized Rep resentative)/Title Address (Owner, Lessee or Authorized Rep.)
L.,
Signature (Owner, Lessee or Authorized Representative Telephone Number
with Notarized Authorization Letter)
STATE OF FLORIDA }
COUNTY OF DADE ) ss:
The foregoing instrument was acknowledged V
ore me this J %� day of J � � 200 �b
y
}} wf t { ' { Ca �' 1 wiho has produced, as identification and who did (did not) take an oath.
4
Notary Public, State of Florida at Large `
Received by Name of DERM Personnel/Section
Dated Signature
THIS IS NOT A NESHAP NOtIFICATION—A SEPARATE NOTIFICATION MUST BE
E
SUBMITTED FOR RENOVATION OR DEMOLITION
161.01-154 8/04 See Reverse Side for Additional Information
Ir