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II. The sites for the <br />() performance of work done m connection with the specific agreement aze <br />listed below: . <br />1. 30o W • Try an ~- <br />• <br />r ~ <br />~~ <br />(street address) <br />ti't~~~s ~rO ~ ~ 2 7Z'~8 <br />(City, ty, state, zip code) <br />2. 2~0) }~orresfeac~ ~d <br />(Street address) <br />~ `<< C 2 ~ s` ~6 <br />(City, county, state, zip code) <br />Contractor will inform the Department of any additional sites for performance of work under this <br />agreement. . <br />False certification or violation of the certification shall be grounds for suspension of payment, <br />suspension or termination of grants, or government-wide Federal suspension or debarment <br />(Section 4 CFR Part 85, Section 85.615 and 86.620). <br />_~~~ ~tre~-fib <br />Authorized ncy Official Signature .Title <br />r <br />Offici Agency Na <br />(Signature should be same as Contract signature) <br />~ /~lv~- <br />Date <br />Drug Free 5/00 <br />Page 2 of 2 <br />