00-0734-006 r
NOTICE OF NESIIAP REQUIREMENTS AND
AFFIDAVIT FOR ASBESTOS SURVEY
'I. ProjeetType: [ ] Demolition ),Renovation [ ] Rooting DERM Process Number ' �.,�'``-�"
€z ' t ?V PiofectAddress IdfirJr`1 1i1 � J��
State ..y Zip Code_>>j 4 County
3': Project Dates(inm/dd./yy): Start�' (r t'�� Finish f' -
4.n Contractor "
tractor 1 ` t_ �.;►j_O�Q k J A s... - Florida License# C r t _ ��` 5
5. '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 thatwill be impacted by the project)
{ _ tA V, iCsr• '_►,'�^_ `��Y.,,,t ,_!�',r�r41 / 1� .:�� .��r�ts►
I the'uiidersigned hereby attest that Fain aw re 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
f referenced property may bq 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;.
pp 4. Pursuant'to 40 CFR 61 subpart M, section,145 (b)and 469.001-015 Florida Statutes, a written notification must be-
E
subm itted to DERM at least 10 working days prior to demolition or asbestos abatement activity at the above referenced
property.
Additionally I am aware that violation of the above referenced regulations may result in civil or criminal prosecution or;
both or penalties and fines of up to$25Y000 per day per violation.
of�/•;iE
Name in Print caner, es ee or`Nd1r1 nze8Representative /Title Business Name
t r
�,
s _ -Telepho 1�e Number
� S�gna iiie(Owner, L ssee orb Litfiorized RWesentative x -
;d� ( o24.zed Authbrizktion Letter is required) '
`—STATE OF FLORIQA ) _ _ �J�
f COUNTY OF DAD )ss.: Permit Applicant, if dif Brent(Print Name and Signature)
The foregoing instrument was acknowledged before me this („ day oft�r 2000 by
who has produced,as identification andwho did(did not)take an oath.
^,I Notary Public, State of Florida at Lar,,e
i I received the signed Asbestos affi4 it from,
d and offered him/her with a copy of the aboveztnentioned applicable regulations.
j' Name of DERM Personnel/Section Dated Signature.
f" -FJIIS_VS NOT A NESHAP NOTIFICATION,
-_ See Reverse Side for Additional Information
•