Admin Order 52-17-03-F - Laserfiche WebLink

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Important: The authorized facility representative must attach to this completed Reporting Exemption Request Form a detailed report prepared by an independent, certified professional, demonstrating evidence that the facility's operations pose little or no risk to public health or the environment. Examples of an independent certified professional include an environmental consultant, an industrial hygienist, or a toxicologist. Certification (Read and sign after completing all sections.) I certify under penalty of law that I have personally examined the information submitted in this form and all attached documents. Based upon my inquiry of those individuals responsible for obtaining the information, I certify that the submitted information is true, accurate and complete. I understand I will be assessed an additional fee (for a maximum cost of $500.00) to cover the City of Eugene's cost of hiring an independent, certified professional to review the information submitted with this form by my facility. I acknowledge that I will have an opportunity to speak with the Eugene Toxics Board regarding the requested exemption, and that I may be asked by the Toxics Board to provide additional information to support this exemption request. I understand that if the Toxics Board grants my business an exemption from the reporting requirement, I am still responsible for the annual program hazardous substance user fee. I also understand that approval or denial of this exemption request is at the discretion of the Toxics Board, and is final. (If the exemption request is denied, the facility may be allowed to amend and resubmit a reporting exemption request within sixty (60) days after denial without incurring an additional $150.00 submission fee.) I declare under penalty of perjury that the foregoing is true and correct. Name and Official Title of owner, facility operator, or senior management official: Name Signature Title Date Signed