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• • • �� vvr t <br />CERTIFICATION ON LAST PAGE <br />J.R. SMITH, CLERK <br />HA Aaach—t L Slam— ofDe:ermination (SOD) Form 4/26,2011 <br />Attachment L <br />Statement of Determination <br />(Check Only One) <br />❑ Exempt from Reporting for Filing Year <br />Deregistration <br />Due to Chemkals Being Removed or Under Thresholdjor 7he Filing Year) <br />(Facility Decommissioned) <br />SITE INSPECTION DATE: <br />FACILITY NAME: <br />PHYSICAL ADDRESS, CITY & ZIP: <br />L E PC: COUNTY: SERC # <br />❑ Extremely Hazardous Substance(s) EHSs WERE present on-site during the current filing year, but only in DATE <br />SECTIONS <br />amounts below the established Threshold Planning Quantities (TPQ). AS OFTHLS DA TE: <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 <br />year. ALL EHSs WEREREMOVEDASOFTHL4DATE.. <br />Extremely Hazardous Substance(s) EHSs WERE present on-site during the current filing year, but only in <br />DATE <br />amounts below the established Threshold Planning Quantities (TPQ). ASOFTALSDATEEHSs <br />WERE present on-site during the during the current filing year but ALL WERE REMOVED AS OF THIS DATE: <br />NO EHSs R'ERE present on-site during the cturent filing year. ALL EHSs WEREMOVEDASOFTHISDATE:Not <br />ISECTIONS <br />within covered NAICS Codes. <br />Within covered NAICS Codes, but less than ten (10) employees. <br />Within covered NAICS Codes, butNO Section 313 chemicals WERE present on-site during the current filing year. <br />DATE <br />ALL SECTION313 CHEMICALS WERE REMOVEDAS OF THISDATE: <br />❑ Within covered NAICS Codes, and Section 13 chemicals WERE present on-site during the current filing year, <br />but only in amounts below the established Threshold Planning <br />DATE <br />Quantities (TPQ). AS OFTHISDATE: <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 ERS(s) WERE ON-SITE: <br />❑ YES [] NO <br />DATE EHS(s) EXCEEDED THE ESTABLISHED TPQ: <br />Further Explanation if Necessary <br />Certification: (Read and Sign Aller CwWledng 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 />d 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 />Terns and Conditions of the Hazards Analysis Agreement. <br />Signotore oJLEPC CoordinarodCoanty Officio/ or Anihorized Representative Date Signed <br />HA Aaach—t L Slam— ofDe:ermination (SOD) Form 4/26,2011 <br />