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Attachment E <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 <br />Name of Inspector (Please print) <br />Site Visit Date <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 />W <br />