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PLAN MAP AMENDMENT <br /> SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> i <br /> FILE NUMBER: <br /> �i a off% <br /> Hazardous+Materfals <br /> Describe any hazardous materialsAwastes that will be present on-site:: o <br /> _'.45 .p- <br /> c'- <br /> i Describe any items of historical or archaeological interest an-.site(e,q.cemeteries or structures): <br /> Describe any on-site or off-site sources of noise or vibration(e.g.freeway noise, heavy equipment,etc. <br /> is near Highway 4 and Escalon Bellota Road. <br /> Describe any on-site v off-site rsources of right of glare(e.g.parking lot lighting,or reffecUve materials used): On site <br /> lighting to <br /> Describe any an-site or off site source of odar(e. .agricultural wastes : None <br /> Describe any displacement of people that will be caused by the project(e.g.numbers of people,housin units <br /> �UTtici I ATtON S1G ATURES, <br />` `ONLY THE OWNER OF.T,HE PROPERTY DR AN AUTHandt6)` CENT,k FELE:°ANX <br /> PE.ICATION' <br /> 1, the Owner/Agent agree,to defend, indemnify, and hold harmless the County and its agents, officers and employees from <br /> any claim,action or proceeding against the Owner/Agent's project. <br /> 1,further,certify under penalty of perjury that I am (check one): <br /> ® Legal property owner(owner includes partner, trustee,grantor,or corporate officer) of the property(s) involved in this <br /> application,or <br /> ❑ !regal agent(attach proof of the owner's consent to the application of the property's involved in this application and <br /> have been authorized to file on their behalf.,and that the forecloing app lication statements are true and correct. <br /> Print Name: ", _ Y �rSignature: Date ? �Cs' <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Si nature: Date: <br /> F.k0EVSVC%PIanning Applicadon Forms% Page 8 of 8 <br />