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2. Deer Park LEPC Membership Information Update

   Please complete this form with contact information for your primary LEPC Representative, your secondary Representative and your 24 hours information used for reverse drills.

4. Facility Name*
5. 24 hour phone number*
7. Address1
9. Address2
11. City
12. State
13. Zip
17. Primary LEPC Rep Name
18. Email address
20. Primary's Phone Number & Cell Phone Number
24. Secondary LEPC Rep Name
25. Email address
27. Secondary Phone Number and Cell Phone Number
31. Plant Manager or Senior Management Official's Name*
32. Email address
34. Plant or Senior Official Phone and Cell Phone Number
38. Subcommittees

    Each member facility is required to serve on at least one Subcommittee:  

    Please select the Subcommittee(s) you wish to join.

39. Name of Representative that will serve on Subcommitte
41. Choices
    -- Select One --Emergency Response/TransportationExecutive CommitteeCommunicationsCommunity Awareness
Leave This Blank:


42. 1. Receive an email copy of this form.
43. Email address

    This field is not part of the form submission.

44. Submit Submit and Print

* indicates a required field