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A TRUE COPY <br />IFWAff 10N ON LAST PA6F <br />Attachment L J I.. BUTLER, CLERK <br />Statement of Determination <br />(Check Only One) <br />❑ Exempt from Reporting for Filing Year ❑ Deregistration <br />Due m Chemicals Being Removed or Under Threshold for the Filing l ear) (Facility Decommissioned) <br />SITE INSPECTION DATE: <br />FACILITY NAME: <br />PHYSICAL ADDRESS, CITY & ZIP: <br />LEPC: COUNTY: SERC # <br />❑ ExtremelyHazardous Substances EHSs WERE resent on-site during the current film <br />O p g g 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 WEREREMOVEDASOFTHISDATE.- <br />SECTIONS <br />❑ Extremely Hazardous Substance(s) EHSs WERE present on-site during the current filing year, but only in <br />amounts below the established Threshold Planning Quantities (TPQ). AS OF THIS DATE: <br />DATE <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 REMOVEDASOFTHISDATE. <br />El 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, but NO Section 313 chemicals WERE present on-site during the current filing year. <br />I) ATE <br />ALL SECTION 313 CAEAHCALS 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 />but only in amounts below the established Threshold Planning Quantities (TPQ). AS OF THIS DATE: <br />DA 1 E <br />CLOSED FACILITY <br />CHEMICALS <br />REMOVED <br />CHEMICALS BELOW <br />ESTABLISHED TPQs <br />FACII.ITY CLOSED/CHEMICALS <br />REMOVED BY DATE: <br />OTHER <br />❑ YES ❑ NO <br />❑ yES ❑ NO <br />❑ YES ❑ NO <br />NEW FACILITY <br />DATE EHS(s) WERE ON-SITE: <br />❑ YES ❑ NO <br />DATE EHS(s) EXCEEDED THE ESTABLISHED TPQ: <br />Farther Explanation it Neeessarv: <br />Certification: (Read and Sign After ComplelingAMAppUcable 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 PateSigned <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/CounpOfficial or Authorized Representative Date Signed <br />HDP -1? -00 IIA AaachmmtL Statement ofDererwiaedon (SOD) Form 4/262021 <br />