00-0734-008 a.
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NOTICE OF NESHAP REQUIREMENTS AND
l AFFIDAVIT FOR ASBESTOS SURVEY
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1' 1. Project Type: [ ] Demolition \ Renovation [ ] Rooting DEI21ti1 Process Number
W P oject Address t
! t'� ��� County t�
E: City _i�tT�r f ,`�,�',�/ t 11/ State Ir I, Zip Code
/ 3. Project Dates(mmldd./yy): Start (, 1 e� ' =F� Finish -f lam,
4. Contractor 1 \i� !'���►1\`•� {> . i'� � • Florida License# _ C�-1 r _ t�"'i � � 14
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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 that will be impacted by the project) 2 �'
E �+`\t\ l 1�����_. ,t 1T�' \c7�,_ �� .'i•�t���1�t��`� / ' f�iJ 1 �l t.l�! I.l��•-P S
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1 the undersigned l�ereby attest that I am aware of the following:
1. Pursuant to 4Q 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 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 6l subpart M, section 145 (c) and 469.001-015 Florida Statutes, all regulated asbestos containing
r materials(RACM) must be removed prior to any demolition activity that impacts the (RACM) at the above referenced
w: property.-,
4. Pursuant to 40 CFR 61 subpart M, section 145.(b) and 469.001-015 Florida Statutes, a written notification must be
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t' submitted to DERM at least 10 working days prior"to demolition or asbestos abatement activity at the above referenced
.-_ property.
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Additionally I am aware that violations of the above referenced regulations may result in civil or criminal prosecution or
both or penalties and fines of up to$25,000 per day per violation. Ve
1.r-of °')tt,r � r'��fi \l�`�1. .''_� r\�
1 Name in Print veer, e see oK utli r e Representatives/Title Business Name
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Sgna (Ow(Owner, L ssee or_ uthorizisctKe�resenLativey telephone Number
(�`ofari?ed-Authorization Letter is required)
J TATE OF FLORIDA _— �!
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COUNTY OF DADE )ss.: Permit Applicant, if different(Print Name and Signature)
! '! 2000 b
The fo-ego'ng instrument was acknowledged before me this ��, day of r � )�1�. Y
t � fr� {'_ tjt'Y- icC 1 I 1 who has produced, as identification and who did(did not)take an oath.
'Votary Pub ic,State of 5lorida at Lar«e
I received the sl1gned Asbestos afti �6t front i
and offered hn»/her with a copy of th- above-mentioned applicable regulation
( JI'
Name of DERM Personnel/Section Dated Signature',-
THIS IS NOT A NESHAP NOTIFICATION
See Reverse Side for Additional Information
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