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<br />PLACE OF PERFORMANCE <br />FOR CERTIFICATION REGARDING DRUG-FREE WORKPLACE <br />REQUIREMENTS <br /> <br />Name: <br />Name of Contractor: <br />Contractor Number: <br />Date: <br /> <br />California Hispanic Commission <br />on Alcohol and Drug AOUse, Inc. <br /> <br />Iz/q/o3 <br /> <br />The Contractor shall insert in the space provided below the site(s) expected to be <br />used for the performance of work under the contract covered by the certification: <br /> <br />Place of Performance (include street address, city, county, state, zip code for each <br />site): <br /> <br />Street Address <br /> <br />City <br /> <br />Phone Number <br /> <br />/qo~ <br /> <br />N. ~11.tjt- <br /> <br />SMI m, ka.. I tit cp ~" <br /> <br />tlc!- 1/.1tf-t;IU <br />