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t deelare that the attached information is correct, that 1c is my intention to
remove soil from the property in accordance with the attached plang and
specifications and information, that I am aware of the provisions of the City
of Port Coquitlam Soil Removal, Regulation Bylaw No. 2666 and that [ will abide
by all applicable provisions of the bylaw and such terms and conditions as
form part of any Soil Removal Permit isaued pursuant to this Application.

Date

Signature of Applicant

Applicant's Name Printed

Received from

(Applicant's name)

, 19 the sum of $

Removal Permit Application Fee.

Receipt No.

City Engineer