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Attachment E <br /> AA <br /> Iq I <br /> FLORIDA STATE EMERGENCY RESPONSE COMMISSION FOR HAZARDOUS MATERIALS <br /> HAZARDS ANALYSIS ON -SITE VISIT CERTIFICATION FORM <br /> Name of Facility ( Please print) <br /> Name of County ( Please print ) <br /> State Emergency Response Commission ( SERC ) Code <br /> Name of Facility Representative ( Please print ) <br /> Facility Representative Signature Site Visit Date <br /> Name of Inspector ( Please print) <br /> Inspector' s Signature Site Visit Date <br /> The individuals signing above certify that a hazards analysis site visit was conducted on the above date . <br /> ❑ Check if facility representative was informed about using FloridaHMIS . org for EPCRA <br /> on - line tiling <br />