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Contact # <br />(Confracfor) <br />II. The site(s) for the performance of work done in connection with the specific agreement are <br />listed below: <br />1. <br />(City, oounty, state, <br />(City, county, state, zip coda) <br />Contractor will inform the County of any additional sites for performance of work under this <br />agreement. <br />False certification ar violation of the certification shall be grounds for sas~ension pf payment, <br />suspension or termination of grants, or government-wide Federal suspanston or debarment <br />(Section 4 CFR Fart 85, Sectton 85.615 and 86.620). ' <br />`~ <br />Signature --._., <br />Title ~r~"O <br />~aroli_nQS ~~ica1_ Center-No ast <br />Agency/Organisation <br />$°$ ~v7 <br />Date <br />(Certification signature should be same as Contract signature) <br />Federal Certification -Drug-Free Workplace (06104) ~~ ~ ~ Page 2 of 2 <br />