00-0734-003 Jo NOTICE OF NESHAP REQUIREMENTS AND
AFFIDAVIT FOR ASBESTOS SURVEY ;s
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f Projec 'ype [- }0oontion- Renovation ] Roofing DERM'ProCess Numbeir f�
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f . �. Ciiry Zip Code County} `3
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y 1rt4ectfes' Ydd:lYY): Start , ." Finish
4• Ctr3 tractor .L,�,.�_', - % i 2_���A to C.. Florida L* ►se# t 63 L 0 c � 111
41, 5 'Give a brief Description of work to be done at the above mentioned address: (Include scope of work,and the estimated
area in squad fetth , +i11 be 'mpacted by the project) ,
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�. frlersigne0lereby att hal)�i aw re of the foiidwinf:
`" 1 ri suant to t CFR 61 subpart M, se ion 1,45 (a)and 469.001-01'5 Florida Statutes aii asbestos suruoy-at the aboy
y4*ferenced property may required for to any,renovation or demolition activity.
2. Pursuant to 40CFR 61,-sttbpan M sect9tin 445 J aT 469.001=415 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 46CF-R 61 subpart M, section 145.(c)and 469.001-015 Florida Statutes, all regulated asbestos containing gti
materials(1CM�trust be remayex#prior#o any demolttion actryity that trnpaets 4h-,,(R 1�CM at the alzgve cefnoecfi }F r$
1 �)ittil�k ,1�uttl w � Flvnda �utes,_& written n4tt [i
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i< ubrrritteil 11i at t4 vt1 +: y5rf t�' + ifbestis �41crf ti+e• lv+�refeene '
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property. `.a
.Additionally I am aware that viola of the above referenced regulations may result in civil or criminal prosecution or/
both br penalties and fines of.up to per day per violation.
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Name in,ftin v►fier, ee u ize epresentativ /Title Business Name +;
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igit (tOw'i�er,L `ssee br r1 _ ��`� w}e- umber= .a _
fhka'Azed Auth i tion Letter is required)
STATE OF FL�R A' )
COUNTY OF DAD . )ss.: Permit Applicant,if di renl(Print Name and Signature)
The' fprego'ng instrinent Was acknowledged before me this y of , '2000,CkenfftOSAIL who has produced,as identification an who did did not)take an oath.
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Notary Pub O;Mate,of.Florida At Lat y
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l received)hel,Asbestos:af
a I and offered hittt�tier with a cop -of at�ov�ntioted aplli'eable regutatiotts
Vorne of DERM Personnel/Section Dated Signature
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!NOT A NESHAP NOTIFICATI+QN� �
a et�gl"se Side for Additional Infortior�
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