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Attachment M Statement of Determination Facility Name Physical Address: LEPC: County SERC # I have determined that this facility is / is not subject to the following section(s) of EPCRA, Title 111, for the reporting year(s) indicated (circle all applicable): SECTION 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 302/303 Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N 311/312 Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N 313 Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N If "No" was indicated on any of the above, please check appropriate box(s) why: Sections Extremely Hazardous Substances (EHSs) are / were present only in amounts less than established 302/303 Threshold Planning Quantities TPQs . No EHSs are Present. No EHSs were present on-site during the year. Sections Hazardous chemicals/EHSs are/were present only in amounts below established reporting thresholds. 311/312 No hazardous chemicals/EHSs are/were present. No hazardous chemicals were present on-site during the year. Section Not within covered SIC Codes. 313 Within covered SIC Codes, but less than ten (10) employees. Within covered SIC Codes, but no Section 313 chemicals were present or were below Section 313 reporting thresholds. Other Closed facility Chemicals removed Chemicals reduced below Date Effective: YES / NO YES / NO threshold/TPQ YES / NO New Facility. Date chemicals brought on site meeting / exceeding TPQ: Further explanation if necessary, CERTIFICATION: I understand the requirements of the law(s) circled above. I also understand that ultimate compliance responsibility lies with me and failure to comply, if required, can result in civil and criminal penalties under federal and state laws. Name of owner/operators authorized representative (printed): Official Title (printed): Signature: JDate signed: 35