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i• stp 18 02 02t32p San Joaquin County 4683127 p.2 <br /> F w - <br />[ �, �y `. <br /> APPLICATION- SITE APPROVAL <br /> AUrHoRlZ4770 hf SW VA TURES <br /> ONLYTHE OIYNEROFI7�IEpROpFR� AN AClTNORTLEOAGENrUAYFlt_EAN APP( AnON. <br /> 1,rhe OaneNABer+tag—,todefena ir+dertt <br /> emPloye.s from any claim.action orproceeding harnttess th.Cougty and f[a agents:otrtCOM and <br /> f+�C.eding agelnst Me OWOWAgent's project. <br /> L further, cerWy+ruder perryty of parj,rha[1 ata(Cheek one): <br /> Leg4p oDertyowr,or( .�rincludes <br /> i involved in this application,or partner,rtnsfee,trwtar,or cprpwm Df/me* <br /> of the pmPenyrsl <br />� ❑ taya!ager[(attach proof o f�e ewrr�'s Consent to the a <br /> aWf Gabon and have hwn avthoNted Oo fife on their ppfieadm of de-p•opwty's urrWyey in this <br /> i <br /> ata true and correct. h d that the fcw"g m9 2pprtr�bn sYatn rifts s <br /> .I Y <br /> Print Name_ � Wi j f /� I <br /> met . a r V <br /> e <br /> Print Namr: <br /> Signarare: <br /> Pr.et Nam.: I <br /> Signature <br /> Daft: <br /> ' Print Nam.; <br /> Si9naluro: <br /> Dote: <br /> l <br /> I <br />