Stratospheric Ozone Protection Program Annual Operating Permit

Department of Regulatory and Economic Resources

Environmental Resources Management

701 NW 1st Court, Suite 700

Miami, Florida 33136-3912

T 305-372-6600 F 305-372-6410

miamidade.gov

Stratospheric Ozone Protection Program

Annual Operating Permit Application

Under Miami-Dade County law (Section 24-25 of the Code of Miami-Dade County, Florida) no persons shall knowingly vent ozone

depleting compounds, such as halons, and refrigerants, into the atmosphere while maintaining, servicing, repairing, or disposing of

equipment (fire extinguishing, refrigeration, air conditioning) that use these compounds. The sale and purchase of ODCs shall be lawful

only when both the seller and purchaser have applied for and obtained a valid operating permit from the Miami-Dade County, Regulatory

and Economic Resources. Approval of recovery and recycling equipment shall be consistent with those currently approved by the U.S.

Environmental Protections Agency (Section 608 of the Clean Air Act).

A fee of $100.00 must accompany this application. Make checks payable to Miami-Dade County.

Instructions:

Please provide the information in full. Submitting this application DOES NOT relieve you of any responsibility for complying with orders issued to you by the CODE

ENFORCEMENT SECTION or stop or delay any normal enforcement procedures. (Must apply in person) Read this application carefully BEFORE you begin to fill out. Call the

Permitting Section at 305-372-6600, if there are questions.

A. Permit To Be Issued To:

Business Name:

Telephone:

Mailing Address: City: State: Zip:

Location Address: City: State: Zip:

Check here if Location Address is your place of residence

Contact Person: Title:

Dade County Occupational License #:

(Enclose a copy)

B. Permit Request For:

Purchase of refrigerants Salvaging or Dismantling Facility

Sale of refrigerants Service Facility (Recharging or Repair)

Does this establishment have any other DERM permits?

No Yes

Permit #

C. Description of Business:

Carlos A. Gimenez, Mayor

D. Description of Recovery/Recycling Equipment: (Enclose purchase receipt or pictures of equipment).

Type (Recovery/Recycle) Manufacturer Model # Serial #

(Attach additional sheet(s) if necessary)

E. List of EPA Certified Technician(s)/Type of Certification(s): (Enclose a Copy)

Name of Technician(s) Type of Certificate/Company EPA Certificate #

F. List the Type of Refrigerants (being sold or used):

(Attach additional sheet(s) if necessary)

The issuing of an AIR POLLUTION CONTROL OPERATION PERMIT for the equipment herein described is subject to FIELD

EVALUATION.

Let in be known that any statements shown on this document are made in full knowledge of the contents of Section 21-24-.1,

Code of Miami-Dade County, titled "False Statements with Intent to Receive Benefit" which states "It shall be unlawful for any

person directly or indirectly, on his own behalf or on behalf of another or others, to make or file, with any officer or employee or

Department or Division of the County, any false statements or representation with knowledge of the falsity thereof and for the

purpose or with intention of receiving for himself or another or others any benefit, including but not limited to, any permit

license, service, certificate, contract." Conviction of a violation of this section is punishable by a $500.00 fine or sixty days

imprisonment, or both. It is with full understanding of all the above that these statement made:

Name in Print (Owner or Corporate Officer) Signature

Business Name

Telephone Number

Personally know , or produced identification . DL #:

Notary:

Notary Stamp