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PLAN MAP AMENDMENT <br /> P <br /> SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> �,41 FILE NUMBER: <br /> 'Hai&dous <br /> Materials <br /> Describe any hazardous materials/wastes that wT be present on-site:, <br /> Diesel fuel and lubricants <br /> Z,� Z <br /> Otheri" <br /> Describe any items of historical or archaeological interest on-site (e.g.cemeteries or structures): <br /> None <br /> Describe any on-site or off-site sources of noise or vibration (e.g.freeway noise, heavy equipment,etc.): <br /> Freeway noise <br /> Describe any on-site or off-site sources of light of glare (e.g. parking lot lighting,or reflective materials used): <br /> None <br /> Describe any on-site or off-site source of odor(e.g.agricultural wastes): <br /> None <br /> Describe any displacement of people that will be caused by the pro'ect(e.g.numbers of 2eople,housing units): <br /> None <br /> AUTHORIZATION SIGNATURES <br /> ONLYTHEOWNER OFTHE PROPERTY:0113 AN'AUTHORIZED AGENT MAY FILE AN APPLICATION <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 /> L Legal property owner(owner includes partner, trustee, grantor, or corporate officer) of the property(s) involved in this <br /> application, or <br /> -Legal 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 Areqo-VQ applic 'on atements are true and correct. <br /> I . <br /> Print Name; (AVSD C. 51 LVA Signature: G Date: /)/?Le <br /> Print Name,.' Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> FADEVSVG\PlanninqAppucalion Forms Page 8 of 8. <br /> General Plan Arnendment.doc.(Revised 3-5-04) <br />