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only and do not change the terms of the document. By signing this document, the UAO hereby represents that <br />no change has been made to the text of this document except through the terms of the Appendix entitled <br />Changes to Form Document." <br />You MUST signify by selecting or checking which of the following applies: <br />® No changes have been made to this Form Document and no Appendix entitled "Changes to Form <br />Document" is attached. <br />El No changes have been made to this Form Document, but changes are included on the attached <br />Appendix entitled "Changes to Form Document." <br />IN WITNESS WHEREOF, the parties hereto have executed this Agreement effective the day and year first written. <br />UTILITY: Indian River County Department of Utility Services. <br />BY: (Signature) DATE: <br />(Typed Name: Susan Adams) <br />(Typed Title: Chairman, Indian River County Board of County <br />Commissioners) <br />Recommend Approval by the District Utility Office <br />BY: (Signature) DATE: <br />FDOT Legal review <br />BY: (Signature) DATE: <br />District Counsel <br />STATE OF FLORIDA <br />DEPARTMENT OF TRANSPORTATION <br />BY: (Signature) DATE: . <br />(Typed Name: ) <br />(Typed Title: ) <br />FEDERAL HIGHWAY ADMINISTRATION (if applicable) <br />BY: DATE: <br />(Typed Name: ) <br />(Typed Title: ) <br />182 <br />