s
1,

Perse ig se

uals RagelXe

(affix profesaional seal)

Signature

Print:

Nane

Address

Address

I, the applicant for the soil deposit permit for deposit of soil at the above
address, acknowledge that I have read this ietter and agree with ita
contents. I have alse reviewed the plans, specifications and supporting
documents attached to this letter and agree with them. I advise you that I
have given name of reglatered
professional the authority to conduct testing, field review and to supervise
the deposit of the soil including the authority to stop the deposit of soil,
remove soil or redirect it as set out in this letter. I acknowledge and
understand that all authority and permission to deposit soil under any permit
issued to me pursuant to any application will automatically cease and be
suspended if the registered professional's services are terminated or limited
and will not be reinstated until such time as another registered professional
submits to you a signed and completed letter in this form.

Witness's Signature Signature of Applicant for
| Permit

Print: Print:

Address Address

The Corporate Seal of

(Corporate Seal) was hereto affixed in the
presence of:

Authorized Signing Officer

Authorized Signing Officer