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II. The site(s) for the performance of work done in connection with the specific agreement are <br />listed below: <br /> <br />Fh`~lsbo~,c~, NC 2TZ7~ <br />~A[ (City, coun~y/ty/~~, state, zip code) ~ _- <br />(Street address) _ .- ~ . <br />~h~~t ill ~ G ~~s°~b <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, Sa;tion 85.61 S and 86.620). <br />Authorized ncy Official Signature <br />C~~.~t ~-f~~-C~f ~, '~Dl~rec~' <br />Tide <br />~Q Ca a .~, _ :~ <br />Official geacy Nam Date _ ..:~.,~~._,_~. _3.... <br />(Signature should be same as Contract sigiiature) <br />Drug Free 5/00 <br />Page 2 of 2 <br />