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Ag�,N h PLAN MAP AMENDMENT <br /> y< SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> FILE NUMBER: -1A --(Y 8 0 LA i <br /> Hazardous Materials <br /> Describe any hazardous materials/wastes that will be present on-site:: <br /> 1112 <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 /> O F r S !t C , 5-FA-7'C 120V—r t5 1747 <br /> Describe any on-site or off-site sources of light of glare (e.g. parking lot lighting, or reflective materials used): <br /> �7 EGC�IC/ Ll�sr7I.v <br /> Describe any on-site or off-site source of odor(e.g. agricultural wastes): <br /> N�[4tit3oatrq QU DPEoe-&Tto9,:F.,, iz S SSP 5 <br /> Describe any displacement of people that will be caused by the project(e.g. numbers of people, housing units): <br /> No 2 ee, r o -r S. <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 Owner/Agent's project. <br /> I. further, certify under penalty of perjury that I am (check one): <br /> ❑ 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 foregoing application/listatements are true and correct. <br /> 1!' <br /> Print Name: /��1Cf74�� 64.0 4 Signature: le i Date: 3,/O 08 <br /> CS?7o� <br /> Print Name: Signature: _ Date: <br /> Print Name: Signature. Date: <br /> Print Name: Signature: Date: <br /> 11 Print Name: Signature: <br /> Date: <br /> F'\DEVSVC\Planning Application Forms\ Page 7 of 7 <br /> Plan Application Amendment.doc (Revised 11-05-07 <br />