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ATTACHMENT M <br />STATEMENT OF DETERMINATION <br />(Check Only One) <br />Exempt from Reporting for Filing Year ❑ Deregistration <br />(Chemicals Removed/Below Thresholds) (Facility Decommissioned) <br />Facility. Name: <br />Physical Address (Street only) <br />LEPC: <br />County: <br />SERC # <br />Sections <br />3021303 <br />Sections <br />3111312 <br />Section <br />313 <br />0 <br />Extremely Hazardous Substances (EHSs) ARE I WERE present only in amounts less than established Threshold Planning Quantities (TPQs). Indicate by <br />circling ARE or WERE if the chemical is or is not present at the facility. Check one (f) of the two (2) boxes Immediately below. <br />0 <br />No EHSs ARE present on-site at the facility during the year. <br />No EHSs WERE present on-site during the year. <br />Hazardous chemicals / EHSs ARE I WERE present only in amounts below established reporting thresholds.. Indicate by circling ARE or WERE rf. the <br />chemical is or is not present at the facility. Check one 1 of the two 2 boxes Immediately below. <br />No hazardous chemicals / EHSs ARE I WERE present. <br />No hazardous chemicals WERE present on-site during the year. <br />Not within covered NIACS Codes. <br />Within covered NIACS Codes, but less than len (10) employees. <br />0 <br />Within covered NIACS Codes, but no Section 313 chemicals were present or were below Section 313 reporting thresholds. <br />Other <br />Closed facility <br />OYES ONO <br />Chemicals removed <br />❑ YES ONO <br />Chemicals reduced below threshold/rP0 <br />OYES ONO <br />Date Effective: <br />New Facility <br />Information: <br />New Facility: Yes f No <br />Date chemicals brought on-site i or <br />Exceeding TPQ: <br />Effective Date: <br />Further Explanation ff Necessary: <br />Certification (Read and Sign After Completing All Sections) <br />1 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 <br />individuals responsible for obtaining the information, I believe that the submitted information is true, accurate and complete <br />Name and Official Title of OwnedOperator OR Owner/Operator's Authorized Representative <br />Signature <br />35 <br />Dale Signed <br />113 <br />