Okaloosa County BOCC — May 17, 2016 — Okaloosa HA Contract 2016-17 — reading text

conducted on the above date. Notes:________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________  Check if facility representative was informed about using E-Plan (https://erplan.net/eplan/login.htm) for EPCRA on-line filing 36  Attachment K 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 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 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 Threshold 302/303 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 / operator’s authorized representative (printed): Official Title (printed): Signature: Date signed: 37  Attachment L HAZARD ANALYSIS REVIEW CRITERIA Facility Page 1. Facility Name 2. Facility Address 3. Facility Phone# 4. Name and phone number for 24-hour contact 5. Evacuation route(s) 6. Legible/Detailed Site Plan (SERC#SP) with location of EHS(s) 7. Site Visit Certification Form (SERC#SV) 8. Latitude & Longitude in Decimal/Degrees 9. Maximum No. of Occupants Chemical In Inventory 1. Proper Chemical Name and Chemical Abstract Number 2. Max Daily Amount 3. Max Amount in Largest Container Scenario Page 1. Amount Released (Must be the same as Max Amount in Largest Container) 2. Release Duration for Gases and Solids in Solution must be 10 Minutes 3. Natural Physical State 4. Risk Assessment 5. Estimate Threat Zone Radius 6. Name of Critical Facilities if None Indicate So 7. Estimate Total Exposed Population 8. SOD or Supporting Documentation 38