01-0679-001 MIAMI�DADE
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O.TICE OF NESHAP REQUIREMENTS AND Air Faclllitigs Sect n
i ,3 33 S.W.2nd Avenue,Suite 9-223
AFFIDAVIT FOR ASBESTOS SURVEY
Miami,Florida 331301540
1. P'PO'ect T e: ]Demolition [;:]Renovation [ ]Roofing DERM Process Number
2. Project Address 7-7
City-5 `�f mi State_Zip Code gg/Y�_County
3. Project Dates(mm/dd./yy): Start 1 2M Finish
JAM 1 2_07
4. Contractor y�tf {� �W'f= LL Florida License# � � -(�/6 _3�4
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)
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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 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. j
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.
4.4. Pursuant to 40 CFR 61 subpart M, section 145 (b) 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 or penalties and fines of up to$25,000 per day per violation.
of -I.,
/ (Name in Print( wn Lessee or Authorized Representative)/Title Business Name
- /
Signature(D Lessee or Authorized Representative) Telephone Number
(Notarized Authorization Letter is required) 1
STATE OF FLORIDA )
COUNTY OF DADE )ss.: Permit Applicant, if different(Print Name and Signature)
The foregoing instrument was acknowledged before me this day of 200 by
who has produced,as identifp�tion and who did(did not)take an oath.
Notary Public,State of Florida at Large
r' I received the signed Asbestos affidavit from l"I
and offered him/her with a copy of the above-mentioned applicable regulations.,y
Name of DERM Personnel/Section 'Dated Signature '
THIS IS NOT A NESHAP NOTIFICATION y ��
See Reverse'Side for Additional Information