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2021-085D
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2021-085D
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Last modified
7/19/2021 3:09:40 PM
Creation date
7/19/2021 3:06:38 PM
Metadata
Fields
Template:
Official Documents
Official Document Type
Contract
Approved Date
06/15/2021
Control Number
2021-085D
Agenda Item Number
8.E.
Entity Name
JSR Enterprises East Coast, LLC.
dba JSR Fueling Technologies, LLC
Subject
Fleet Facility Fuel Island Canopy Refurbishment
Project Number
IRC-2025
Bid Number
2021024
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IRC-2025—ITB—FLEET FACILITY GAS ISLAND CANOPY REFURBISHMENT <br />entity, have any relationships as defined in section 105.08, Indian River County Code, with any <br />County Commissioner or County employee. <br />The entity submitting this sworn statement, or one or more of the officers, directors, <br />executives, partners, shareholders, employees, members, or agents, who are active in <br />management of the entity have the following relationships with a County Commissioner or <br />County employee: <br />Name of Affiliate Name of County Commissioner Relationship <br />or entity or employee <br />C-. <br />O` (S" nature) <br />(Date) <br />STATE OF F (v - r/` <br />COUNTY OFC ova --2 <br />Sworn to (or affirmed) and subscribed before me by means of 19''physical presence or ❑ online <br />notarization, this Q.5 day of 2021 , by c -Ay (name of person making <br />statement). May <br />(�ignature of Nota Public - Sta e of Florida) <br />(Print, Type, or Stamp Commissioned Name of Notary Public) <br />❑ who is personally known to me or E?;; ho has produced <br />)_ "-Pr C'(u I�t�V's 4 ; c -"3f e as identification. <br />Page 21 of 39 <br />
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