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.