EXEMPTION LETTER FORM

Instructions: Please read carefully and complete the appropriate information. After completion, send a copy to the Arizona State Emergency Response Commission, the fire department/district that has jurisdiction and to the Local Emergency Planning Committee. See enclosed LEPC Contact List for appropriate addresses.

Name of Company or Facility: ___________________________________________________________

Street Address: (DO NOT use P.O. Box) _______________________________________________________

City, State & Zip Code: _________________________________________________________________

CHECK THE APPROPRIATE BOX AND COMPLETE THE REQUIRED INFORMATION

o This company or facility is not required to submit a Tier Two Emergency and Hazardous Chemical Inventory Form because it meets the following exemption (See Tier Two Instructions for list of exemptions) ________________________________________________________________________________________________________________________________________________________________________

o This company or facility is not required to submit a Tier Two Emergency and Hazardous Chemical Inventory Form because it does not (Check appropriate)

m store, produce or use any of the chemicals that appear on the list of Extremely Hazardous Substances in quantities equal to or greater than the listed Threshold Planning Quantity (TPQ) or 500 lbs which ever is less.

m store, produce or use any other chemicals in amounts equal to or greater than 10,000 pounds that require a Material Safety Data Sheet to be prepared or available in accordance with OSHA regulations.

o This company or facility has previously submitted a Tier Two Emergency and Hazardous Chemical Inventory Form, but is no longer required to submit a report (Check appropriate)

m because it no longer stores, produces or uses any chemical that meets the minimum reporting threshold.

m because the company or facility is no longer active or in business

m because underground storage tanks have been removed

m (other)_____________________________________________________________________

__________________________________________________________________________

Certification: I certify under penalty of law that I have personally examined and am familiar with the information submitted on this page and I believe that the submitted information is true, accurate and complete.

____________________________________ ______________________________________

Date Signed Name & Title

______________________________________

Signature