Okaloosa County BOCC — October 15, 2013 — Okaloosa Hazard Analysis Contract 2013-2014 — reading text

principals is presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from participation in this transaction by any Federal department or agency. (2) Where the Recipient’s subcontractor is unable to certify to the above statement, the prospective subcontractor shall attach an explanation to this form. SUBCONTRACTOR: ______________________________ By:____________________________ Okaloosa County Signature Recipient’s Name ________________________________ 14-CP-11-01-56-01-XXX Name and Title Agreement Number ________________________________ Street Address ________________________________ City, State, Zip ________________________________ Date  Attachment I STATEMENT OF DETERMINATION Facility Name Physical Address (Street only) City County LEPC District I have determined that this facility is / is not subject to the following section(s) of EPCRA, Title III, for the reporting year(s) indicated (circle all applicable): SECTION 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 302 / 303 Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N 311 / 312 Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N 313 Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N If “No” was indicated on any of the above, please check appropriate box(s) why: Sections Extremely Hazardous Substances (EHSs) are / were present only in amounts less than established 302/303 Threshold Planning Quantities (TPQs). No EHSs are Present. No EHSs were present on-site during the year. Sections Hazardous chemicals/EHSs are/were present only in amounts below established reporting thresholds. 311/ 312 No hazardous chemicals/EHSs are/were present . No hazardous chemicals were present on-site during the year. Section Not within covered SIC Codes. 313 Within covered SIC Codes, but less than ten (10) employees. Within covered SIC Codes, but no Section 313 chemicals were present or were below Section 313 reporting thresholds. Other Closed facility Chemicals removed Chemicals reduced below Date Effective: YES / NO YES / NO threshold/TPQ YES / NO New Facility. Date chemicals brought on site meeting / exceeding TPQ: Further explanation if necessary: ________________________________________________________________________ ____________________________________________________________________________ CERTIFICATION: I understand the requirements of the law(s) circled above. I also understand that ultimate compliance responsibility lies with me and failure to comply, if required, can result in civil and criminal penalties under federal and state laws. Name of owner/operators authorized representative (printed): Official Title (printed): Signature: Date signed:  EXHIBIT – 1 STATE RESOURCES AWARDED TO THE RECIPIENT PURSUANT TO THIS AGREEMENT CONSIST OF THE FOLLOWING: SUBJECT TO SECTION 215.97, FLORIDA STATUTES: Division of Emergency Management, Florida Hazardous Materials Planning and Prevention Program, Catalog of State Financial Assistance Number 31.067 in the amount of $12,627.00. COMPLIANCE REQUIREMENTS APPLICABLE TO STATE RESOURCES AWARDED PURSUANT TO THIS AGREEMENT ARE AS FOLLOWS: 1. Emergency Planning and Community Right-to-Know Act (EPCRA), Title III of the Superfund Amendments and Reauthorization Act of 1986, 42 U.S.C. s. 11001, et seq. (SARA). 2. Florida Emergency Planning and Community Right-to-Know Act, Chapter 252, Part II, Florida Statutes