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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: COUNTY: SERC # <br />❑ Extremely Hazardous Substance(s) EHSs WERE present on-site during the current filing year, but only in DATE <br />SECTIONS amounts below the established Threshold Planning Quantities (TPQ). ASOFTIIISDATE: <br />302-303 ❑ EHSs WERE present on-site during the during the current filing year butALL WERE REMOVED AS OF THIS DATE: <br />❑ NO EHSs WERE present on-site during the current filing year. ALL EIISs WEREREMOVEDASOFIMS DATE. <br />❑ Extremely Hazardous Substance(s) EHSs WERE present on-site during the current filing year, but only in DATE <br />SECTIONS amounts below the established Threshold Planning Quantities (TPQ). AS OF THIS DATE: <br />311-312 ❑ 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. ALLEHSs WEREREMOVEDAS OF THIS DATE. <br />❑ Not within covered NAICS Codes. <br />SECTION ❑ Within covered NAICS Codes, but less than ten (10) employees. <br />313 ❑ Within covered NAICS Codes, butNO Section 313 chemicals WERE present on-site during the current filing year. 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, DATE <br />but only in amounts below the established Threshold Planning Quantities (TPQ). AS OF THIS DATE: <br />CLOSED FACILITY CHEMICALS CHEMICALS BELOW FACILITY CLOSED/CHEMICALS <br />REMOVED ESTABLISHED TPQs REMOVED BY DATE: <br />OTHER ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO <br />NEW FACILITY DATE EHS(s) WERE ONSITE: <br />❑ YES ❑ NO DATE EHS(s) EXCEEDED THE ESTABLISHED TPQ: <br />Further Explanation ifNecessarP: <br />Certification: (Read and Sign After 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 <br />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 Official or Authorized Representative <br />Date Signed <br />47 <br />HW -13-00 NA Anachment L Statement of Determination (SOD) Form 4/26/2021 <br />