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PLAN MAP AMENDMENT <br /> w { SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> �q<iFaRa;P FILE NUMBER: - <br /> Hazardous Materials <br /> Describe any hazardous materials/wastes that will be present on-site:: <br /> Other <br /> Describe any items of historical or archaeological interest on-site(e.g.cemeteries or structures): <br /> Describe any on-site or off-site sources of noise or vibration (e.g.freeway noise, heavy equipment,etc.): <br /> N <br /> Describe any on-site or off-site sources of light of glare(e.g. parking lot lighting, or reflective materials used): <br /> AIA <br /> Describe any on-site or off-site source of odor(e.g.agricultural wastes): <br /> Describe any displacement of people that will be caused by the project(e.g. numbers of people,housing units): <br /> /v <br /> AUTHORIZATION SIGNATURES <br /> ONLY THE OWNER OF THE PROPERTY OR AN AUTHORIZED AGENT MAY FILE AN APPLICATION. <br /> I, the Owner/Agent agree, to defend, indemnify, and hold harmless the County and its agents, officers and employees <br /> from any claim, action or proceeding against the County arising from the Owner/Agent's project. <br /> I,,further, certify under penalty of perjury that I am (check one): <br /> 0y regal property owner(owner includes partner, trustee, grantor, or corporate officer)of the property(s) involved in <br /> this application, or <br /> ❑ Legal agent(attach proof of the owners 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 foregoing a licatio statements are true and correct. <br /> Print Name: �P -P.r' W�ST4iax.�� Signature: ,! Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> FADEMC\Planning Application Forms\ Page 8 of 8 <br /> Plan Application Amendmentdw.(Revised 05-71-09 <br />