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ATTACHMENT M <br />Statement of Determination <br />(Check Only One) <br />0 Exempt from Reporting for Filing Year 0 Deregistration <br />(Chemicals Removed/Below Thresholds) <br />(Facility Decommissioned) <br />Facility Name: <br />Physical Address -City, Zip <br />LEPC: <br />County: <br />SERC ID: <br />Sections <br />3021303 <br />Extremely Hazardous Substances (EHSs) ARE present only in amounts less than established <br />Threshold Planning Quantities (TPQs) as of this date: <br />No EHSs WERE present on-site during the current filing year. ALL EHSs were removed as of this date: <br />Sections <br />311/ 312 <br />EHSs ARE present only in amounts below established Threshold Planning Quantities as of this date: <br />No EHSs WERE present on-site during the current filing year. <br />List the date ALL EHSs were removed: <br />Section <br />313 <br />Not within covered NAICS Codes. <br />Within covered NAICS Codes, but less than ten (10) employees. <br />Within covered NAICS Codes. but no Section 313 chemicals WERE present or WERE BELOW Section <br />313 reporting thresholds. <br />Other <br />Closed Facility: <br />YES n NO <br />Chemicals Removed: <br />YES (-f NO <br />Chemicals reduced below TPQ: <br />n YES I I NO <br />Date Effective: <br />Further explanation if necessary: <br />Certification (Read and sign after completing all sections) <br />I certify under penalty of law that I have personally examined and am familiar with the information submitted on this page, and that based on my inquiry of those individuals <br />responsible for obtaining the information, I believe that the submitted information is true, accurate and complete <br />Name and Official Title of Owner/Operator OR Owner/Operator's Authorized Representative <br />Signature Date Signed <br />HMP -13-00 <br />