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r4u1 PLAN MAP AMENDMENT SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT FILE NUMBER: I %FOHN I 1 Hazardous Materials 11 Describe anv hazardous materials/wastes that will be present on-site:: NIA Other Describe any items of historical or archaeological interest on-site(e.g.cemeteries or structures): Describe any on-site or off-site sources of noise or vibration(e.g.freeway noise,heavy equipment,etc.): Describe any on-site or off-site sources of light of glare(e.g.parking lot lighting,or reflective materials used): Describe any on-site or off-site source of odor(e.g.agricultural wastes): Describe any displacement of people that will be caused by the project(e.g. numbers of people,housing unitHAA AUTHORIZATION SIGNATURES ONLY THE OWNER OF THE PROPERTY OR AN AUTHORIZED AGENT MAY FILE A I, the Owner/Agent agree, to defend, indemnify, and hold harmless the County and its agents, o from any claim,action or proceeding against the County arising from the Owner/Agent's project. 1,,further,certify under penalty of pequry that I am (check one): LVA Legal property owner(owner includes partner,trustee,grantor, or corporate officer)of the prop this application, or ❑ Legal agent(attach proof of the owner's consent to the application of the property's involved in this application and have been authorized/to file on their behalf., and that the foregoing application statements are true and correct. Print Name: kA Ya M ( Sl n� Signature: — '��--� Date: 0 1310 7 1 Print Name: Signature: Date: Print Name: Signature: Date: Print Name: Signature: Date: Print Name: Si o nature: Date: I FIDEVSVCtPlanning Appliwtlon Fams\ Page 7 of 7 Plan Application Amandment.doc.(Revised 05-11-09 1 'I