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PLAN MAP AMENDMENT <br /> SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> FILE NUMBER: - <br /> gCIFORN <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 /> Describe any on-site or off-site sources of light of glare(e.g.parking lot lighting,or reflective materials used): <br /> Describe any on-site or off-site source of odor(e.g.agricultural wastes): <br /> bn➢� <br /> Describe any displacement of people that will be caused by the project(e.g. numbers of people, housing units): <br /> KYR <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 Cou-rtty and its agents, officers and-employees <br /> from any claim, action or proceeding against the County arising from the Owner/Agents project. <br /> 1,, further, certify under penalty of perjury that I am (check one): <br /> ft?/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 a licati n statements are true and correct. <br /> Print Name: \ R\(�D E S i N Cn%Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> FDEMCWIanning Application Fonns\ Page 7 of 7 <br /> Plan Application Amendmentdoc(Revised 05-11-09 <br />