AND I made the solemn declaration conscientiously believing it to be true, and knowing thar it
is of the same force and effect as if made under oath and by virtue of the Canada Evidence Act.

DECLARED BEFORE ME at

in the Province of British Columbia

this day of

19

Nee Ne Nee Nee Nee Ne Nae Se Ne Nee Se Se” ee eet ee ee”

A Notary Public in the
Province of British Columbia
A Commissioner for taking
Affidavits for British Columbia

THIS DECLARATION MUST BE SUBMITTED TO THE CITY OF PORT COQUITLAM
WITHIN ONE MONTH OF THE EXPIRY OF A SOIL REMOVAL PERMIT. ;