THE CORPORATION OF THE CITY OF PORT COQUITLAM "SOIL DEPOSIT REGULATION BYLAW N0Q. 2826" SCHEDULE "D" DECLARATION PERMIT NO. EXPIRY DATE PERMIT FEE PAID based on cubic metres. $ AMOUNT ENCLOSED ($.10 per cubic metre in excess of quantity specified in permit) CANADA ) IN THE MATTER OF THE CITY OF PORT PROVINCE OF BRITISH ) COQUITLAM SOIL DEPOSIT BYLAW NO COLUMBIA ) 2826, 1993, AND PERMIT NO ; I, (permit holder) of (address) IN THE PROVINCE OF BRITISH COLUMBIA DO SOLEMNLY DECLARE THAT: I am the (Owner, Lessee, Signing Officer of Limited Company) of (Address) That I have personal knowledge hereinafter deposed. I hereby declare that during the period to the volume of soil deposited on the lands described on Permit Number issued to on the day of in the year cubic metres.