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❑Exempt from Reporting for <br />Filing Year <br />*Due to chemicals being <br />under threshold for the <br />filing year <br />Attachment L <br />Statement of Determination <br />(Check Only One) <br />❑Deregister Facility <br />*Facility closed and <br />all chemicals <br />removed <br />*Facility open and all <br />chemicals removed <br />*Chemicals <br />permanently reduce to <br />below threshold <br />Facility/Chemical Status Change <br />*Facility Sold <br />*One or more chemicals <br />removed, other <br />substances remain <br />above threshold <br />Facility Name: <br />Street: City: Zip: <br />LEPC:County: <br />:1 <br />SERC ID or <br />Access ID: <br />SECTIONS <br />302-303 <br />Extremely Hazardous Substances (EHSs) WERE present only in amounts less than established <br />Threshold Planning Quantities (TPQs) as of this date: <br />NO EHSs were present on-site during the current filing year. <br />ALL EHSs were removed as of this date: <br />SECTIONS <br />311-312 <br />Hazardous Substances (HSs)/EHSs WERE present only in amounts below <br />established Threshold Planning Quantities (TPQs) as ofthis date: <br />NO Hazardous Substances (HSs)/EHSs WERE present on-site during the <br />current filing ear. List the date ALL HS& EHSs were removed: <br />STATUS <br />CHANGE <br />Closed Facility: <br />❑YES❑NO <br />Chemicals Removed: <br />El YES []No <br />Chemicals Permanently Below TPQ: <br />❑YESQNO <br />Date Effective: <br />Further Explanation (ex: facility sold with date, name and CAS Number of chemical removed/reduced chemical, etc.): <br />Certification: (Read and sign after completing all sections) <br />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 <br />individuals responsible for obtaining the information, I believe that the submitted information is true, accurate and complete. <br />Name and Official Title of Owner / Operator OR Owner / Operator's Authorized Representative <br />Signature <br />HMP -13-00 <br />32 <br />Date Signed <br />Form Updated 41"025 <br />