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Name of Affiliate <br /> Name of County Commissioner Relationship <br /> or entity or employee <br /> ignature ) <br /> , <br /> ( Date ) <br /> STATE OF <br /> COUNTY OF <br /> The foregoing instrument was acknowledged before me this/day of , 2004 by <br /> who is personally known to me or who <br /> has produced �DfOK5 C' C �SE_ as <br /> identification . <br /> NOTARY PU IC <br /> SIGN : <br /> PRINT : <br /> State of Florida at Large <br /> My Commission Expires : <br /> ( Seal ) 00 % T M" <br /> W CW nWWM 00M= <br /> or EVWa W" 23, TOGS <br /> F :\Public Works\Capital Projects\Hurricane Debris Removal\emergency contract CoastaiMULCH . doc 2 <br />