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PLAN MAP AMENDMENT � <br /> a ` SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> FILE NUMBER: - <br /> ciFd"y' <br /> 01 <br /> Describe any'hazardous materialstW`stise that Yi10 be pri on-site:: <br /> r 4;1111 <br /> K , ii , f. . . <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 /> wrl AW 4,1 G'577 c� SPva <br /> Describe any on-site or off-site sources of light of glare(e.g.parking lot lighting,or reflective materials used): <br /> lc�,v- t 704 Gf JAZZ <br /> Describe any on-site or off-site source of odor(e.g.agricultural wastes): <br /> 0 %tie <br /> Describe any displacement of people that will be caused by the project(e.g. numbers of people,housing units): <br /> prl6' <br /> AUTHORIZATION SIGNATURES <br /> ONLY THE OWNER OE THE PROPERTY OR 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 <br /> from any claim, action or proceeding against the Owner/Agent's project. <br /> I,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 <br /> this 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 forepoing application statements are true and correct. <br /> Print Name: T /4n/ Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Si nature: Date: <br /> F:IDEVSVCIPIannirg Application Forms\ Page 7 of 7 <br /> Plan Application Amendment.doc.(Revised 6-03-04) <br />