La Porte, Morgan’s Point, & Shoreacres LEPC
604 W Fairmont Parkway
La Porte, TX 77571
2021 LEPC CONTRIBUTION WORKSHEET
For dues, fees & assessments for 1/1/2021 through 12/31/2021
Please complete the payment information below. If your facility requires an invoice for payment,
submit this form and a request for an invoice to LEPC@laportetx.gov.
Company Name: _______________________________________________________________________________________
Company Address: ______________________________________________________________________________________
Contact Name: ______________________ Phone Number: ______________________ Email: _________________________
Membership Category Dues, Fees, & Assessments Amount
Companies that use, manufacture, or process any hazardous chemical
subject to the Environmental Protection Agency’s (EPA) List of Lists*
*Manufactured = to produce, prepare, import, or compound a toxic chemical
*Process = the preparation of a toxic chemical, after its manufacture, for
distribution in commerce, (1) in the same form or physical state as, or in a different
form or physical state from, that in which it was received by the person so
preparing such chemical, or (2) as part of an article containing the toxic chemical.
Fair Share Dues: $500
(For purposes of the 2021 fees calculation, the definition of an employee is
company employees plus nested/core contract personnel x 4.50 per person)
Total Number of Company Employees:
Total Number of Contractors (Nested/Core):
Total Number of Employees/Contractors: __ x 4.50 = $ _____
Employee Headcount Fee
Responsible agency or jurisdiction, transportation companies,
pipeline companies, product warehouses
Fair Share Dues
Non-profit organizations, citizens
Fair Share Dues
TOTAL DUES, FEES, & ASSESSMENTS
*List of Lists = Consolidated list of chemicals subject to the Emergency Planning and Community Right-to-Know Act (EPCRA),
Comprehensive Environmental Response, Compensation and Liability Act (CERCLA), and Section 112(r) of the Clean Air Act.
List can be accessed at: https://www.epa.gov/sites/production/files/2015-03/documents/list_of_lists.pdf
Mail Annual Membership Application and Payment To:
La Porte LEPC; 604 W Fairmont Pkwy, La Porte TX 77571
Please make checks/money orders payable to: La Porte LEPC
Credit card payments are accepted; however, a transaction fee of 4% will be added to the contribution total.
Contributions or gifts to La Porte LEPC are not tax deductible as charitable contributions for Federal income tax purposes.
A member must participate financially to be a “Voting Member” of the LEPC under the Articles of Organization and Bylaws.
Questions? Contact the LEPC Coordinator at LEPC@laportetx.gov or 281-470-0010.