I, the applicant for the soil removal permit for removal of soil from the above address,
acknowledge that I have read this letter and agree with its contents. I have also reviewed the
plans, specifications, and supporting documents attached to this letter and agree with them. |
advise you that I have given:

name of registered professional

the authority to conduct testing, field review and to supervise the removal of the soil including
the authority to stop the removal of soil, deposit soil, or redirect it as set out in this letter. I
acknowledge and understand that all authority and permission to remove 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 re-instated until such
time as another registered professional submits to you a signed and completed letter in this form.

Witness’s Siguature Signature of Applicant for Permit

Print Print

Name Name

Address Address

The Corporate Seal of

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

Authorized Signing Officer

Authorized Signing Officer