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Attachment K <br />STATEMENT OF DETERMINATION <br />Facility Name <br />Physical Address (Street only) <br />City <br />County <br />LEPC District <br />I have determined that this facility is / is not subject to the following section(s) of EPCRA, Title III, for the reporting year(s) indicated <br />(circle all applicable): <br />SECTION <br />2009 <br />2010 <br />2011 <br />2012 <br />2013 <br />2014 <br />2015 <br />2016 <br />2017 <br />2018 <br />2019 <br />302/303 <br />Y/N <br />Y/N <br />Y/N <br />Y/N <br />Y/N <br />Y/N <br />Y/N <br />Y/N <br />Y/N <br />Y/N <br />Y/N <br />311/312 <br />Y/N <br />Y/N <br />Y/N <br />Y/N <br />Y/N <br />Y/N <br />Y/N <br />Y/N <br />Y/N <br />Y/N <br />Y/N <br />313 <br />Y/N <br />Y/N <br />Y/N <br />Y/N <br />Y/N <br />Y/N <br />Y/N <br />Y/N <br />Y/N <br />Y/N <br />Y/N <br />If "No" was indicated on any of the above, please check appropriate box(s) why: <br />Sections <br />302/303 <br />CERTIFICATION: <br />I understand the requirements of the law(s) circled above I also understand that ultimate compliance <br />responsibility lies with me and failure to comply, if required, can result in civil and criminal penalties under federal <br />and state laws <br />Extremely Hazardous Substances (EHSs) are / were present only in amounts less than established <br />Threshold Planning Quantities (TPQs). <br />Official Title (printed): <br />No EHSs are Present. <br />No EHSs were present on-site during the year <br />Sections <br />311/ 312 <br />Hazardous chemicals/EHSs are/were present only in amounts below established reporting thresholds. <br />No hazardous chemicals/EHSs are/were present. <br />No hazardous chemicals were present on-site during the year <br />Section <br />313 <br />Not within covered SIC Codes. <br />Within covered SIC Codes, but less than ten (10) employees. <br />Within covered SIC Codes, but no Section 313 chemicals were present or were below Section 313 reporting <br />thresholds. <br />Other <br />Closed facility <br />YES / NO <br />Chemicals removed <br />YES / NO <br />Chemicals reduced below <br />threshold/TPQ YES / NO <br />Date Effective: <br />New Facility Date chemicals brought on site meeting / exceeding TPQ: <br />Further explanation if necessary: <br />31 <br />CERTIFICATION: <br />I understand the requirements of the law(s) circled above I also understand that ultimate compliance <br />responsibility lies with me and failure to comply, if required, can result in civil and criminal penalties under federal <br />and state laws <br />Name of owner / operator's authorized representative (printed): <br />Official Title (printed): <br />Signature: Date signed: <br />31 <br />