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A TRUE COPY <br />CERTIFICATION ON LAST PAGE <br />J.R. SMITH, CLERK <br />ATTACHMENT L <br />Statement of Determination <br />(Check Only One) <br />❑ Exempt from Reporting for Filing Year ❑ Deregistration <br />Due to Chemicals Being Removed or Under Threshold for the Filing Year) (Facility Decommissioned) <br />SITE INSPECTION DATE: <br />FACILITY NAME: <br />PHYSICAL ADDRESS, CITY &ZIP: <br />LEPC: <br />COUNTY: SERC it <br />❑ Extremely Hazardous Substance(s) EHSs WERE present on-site during the current filing year, but only in <br />DATE <br />SECTIONS <br />amounts below the established Threshold Planning Quantities (TPQ). AS OF THIS DATE: <br />302-303 <br />❑ EHSs WERE present on-site during the during the current filing year but ALL WERE REMOVED 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 />❑ Extremely Hazardous Substance(s) EHSs WERE present on-site during the current filing year, but only in <br />DATE <br />SECTIONS <br />amounts below the established Threshold Planning Quantities (TPQ). ASOFTHISDATE: <br />311-312 <br />❑ EHSs WERE present on-site during the during the current filing year but ALL WERE REMOVED 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 />❑ Not within covered NAICS Codes. <br />SECTION <br />❑ Within covered NAICS Codes, but less than ten (10) employees. <br />313 <br />❑ Within covered NAICS Codes, butNO Section 313 chemicals WERE present on-site during the current filing year. <br />DATE <br />ALL SECTION 313 CHEMICALS WERE REMOVED AS OF THIS DATE: <br />❑ Within covered NAICS Codes, and Section 13 chemicals WERE present on-site during the current filing year, <br />DATE <br />but only in amounts below the established Threshold Planning Quantities (TPQ). AS OF THIS DATE: <br />CLOSED FACILITY <br />CHEMICALS <br />REMOVED <br />CHEMICALS BELOW <br />ESTABLISHED TPQs <br />FACILITY CLOSED/CHEMICALS <br />OTHER <br />❑YES ❑ NO <br />❑ YES ❑ NO <br />❑ YES ❑ NO <br />REMOVED BY DATE: <br />NEW FACILITY <br />DATE EHS(s) WERE ON-SITE: <br />❑ YES ❑ NO <br />DATE EHS(s) EXCEEDED THE ESTABLISHED TPQ: <br />Further Explanation ilNecessarv: <br />Certification: (Read and Sign Aller Completing All Applicable Sections) <br />I certify under penalty of law that I have personally examined and am familiar with the information submitted on this page, <br />and that based on my inquiry of those individuals responsible for obtaining the information, <br />I believe that the submitted information is true, accurate, and complete. <br />Printed Name of Owner/Operator OR Owner/Operator's Authorized Representative <br />Signature Date Signed <br />By signing this Form, I certify to the best of my knowledge and belief that the information reported is in accordance with the <br />Terms and Conditions of the Hazards Analysis Agreement. <br />Signature of LEPC Coordinator/County Oficial or Authorized Representative Date Signed <br />HMP -13-00 29 2021-22 NA Anach-0 L Statement ofDaermtnntion (SOD) Form 412612021 <br />