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ATTACHMENT L Statement of Determination (Check Only One) ❑ Exempt from Reporting for Filing Year Due to Chemicals Being Removed or Under Threshold for the Filing Year) SITE INSPECTION DATE: FACILITY NAME: ATRUE COPY PAGE J.R. SMITH, CLERK ❑ Deregistration (Facility Decommissioned) PHYSICAL ADDRESS, CITY & ZIP: LEPC: I COUNTY: SERC # ❑ Extremely Hazardous Substance(s) EHSs WERE present on-site during the current filing year, but only in BATE SECTIONS amounts below the established Threshold Planning Quantities (TPQ). AS OF THIS DATE. 302-303 ❑ EHSs WERE present on-site during the during the current filing year. DATE ❑ NO EHSs WERE present on-site during the current filing year. ALL EHSs WERE REMOVED AS OF THIS DATE: SECTIONS ❑ Extremely Hazardous Substance(s) EHSs WERE present on-site during the current filing year, but only in amounts below the established Threshold Planning Quantities (TPQ). AS OF THIS DATE: DATE 311-312 ❑ EHSs WERE present on-site during the during the current filing year. DATE ❑ NO EHSs WERE present on-site during the current filing year. ALL EHSs WERE REMOVED AS OF THIS DATE: ❑ Not within covered NAICS Codes. SECTION ❑ Within covered NAICS Codes, but less than ten (10) employees. 313 ❑ Within covered NAILS Codes, but NO Section 313 chemicals WERE present on-site during the current filing DATE year. ALL SECTION 313 CHEMICALS WERE REMOVED AS OF THIS DA TE. ❑ Within covered NAICS Codes, and Section 13 chemicals WERE present on-site during the current filing year, DATE but only in amounts below the established Threshold Planning Quantities (TPQ). AS OF THIS DATE: OTHER CLOSED FACILITY ❑ YES ❑ NO CHEMICALS REMOVED ❑ YES ❑ NO CHEMICALS BELOW ESTABLISHED TPQs ❑ YES ❑ NO FACILITY CLOSEDIC'HEMICALS REMOVED BY DATE: NEW FACILITY DATE ERS(s) WERE ON-SITE: ❑ YES ❑ NO DATE EHSs) EXCEEDED THE ESTABLISHED TPQ: Further Explanation ifNeeessa Certification: (Read and Sign After Completing All Applicable Sections) 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 responsible for obtaining the information, I believe that the submitted information is true, accurate, and complete. Printed Name of Owner/Operator OR Owner/Operator's Authorized Representative .Signature Date Signed By signing this Form, I certify to the best of my knowledge and belief that the information reported is in accordance with the terms and conditions of this Agreement. Signature of LEPC CoordinatorlCounty Official or Authorized Representative Date Signed JINT-13-00 39 2010-21 HA AaachmetaL Statement of Determinadon (SOD) Foran Updated on 6/10/1010