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ATTACHMENT K <br />Hazards Analysis Site Visit (SV) Certification Form <br />2020-2021 Hazards Analysis Grant <br />0 AOO do, " 0 <br />PLEASE PRINT <br />FACILITY NAME <br />STREET ADDRESS, CITY & ZIP CODE <br />COUNTY <br />NAME OF FACILITY REPRESENTATIVE <br />ATRUE COPY <br />CERTIFICATION ON LAST PAGE <br />J.R. SMITH, CLERK <br />SERC ID # <br />FACILITY REPRESENTATIVE SIGNATURE DATE SIGNED <br />SITE VISIT PERFORMED BY SITE VISIT DATE <br />SIGNATURE <br />The Individuals signing above certify that a Hazards Analysis Site Visit was conducted on the date listed above. <br />1-1 If a telephone update was conducted instead of site visit, please check the box. <br />NOTES <br />Check if facility representative was informed about using E -Plan for EPCRA Tier II on-line filing. <br />(https://eiplan.net/eplan/login.htm) <br />38 <br />1020-21 HA Attachment X Hazards Analysis Site Visit (SV) Certification Form Updated 6110/1010 <br />