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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 />~ oo W . I r' y o ~n ~~-r cG'f"' <br />address) <br />~~ l is Iv v r D u,~,(~-~ IV C. Z~ Z 7 8 <br />(City, cou~ity, state, zip Conde) <br />2. LSD 1 ~es+e~ 1~-0 <br />(Street address) <br />~~l«.Pe~ ~l`I( ~C ZZ~iy <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 />Authorized A ncy Officia! Signature <br />~'~'Q•v~ ~ Cb Uiv1~y 'rT ~° 4~.~ <br />Official Agency Name <br />(Signature should be same as Contract signature) <br />DPH Drug Free 1/02 <br />Page 2 of 2 <br />Title <br />Date <br />~ ~ <br />_ PLEASE ACCEPT AS ORIGINAL SIGNATURES _ <br />