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°"4utM PLAN MAP AMENDMENT <br /> >.•�t FA;G <br /> L' <br /> < SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> FILE NUMBER: <br /> �/FOR <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 /> / <br /> t <br /> Describe any on-site or off-site sources of light of glare(e.g. parking lot lighting, or reflective materials used):// <br /> - I d k <br /> Y <br /> i �i <br /> Describe any on-site or ff-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 /> 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 /> �f 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 applicption statemerA are true and correct. <br /> Print Name: /W r/es _ tu e-eir t Signature: Kr14 Date: <br /> Print Name:y�/�Q .�� 45- 4J,e-eaT Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: - Date: <br /> Print Name: Signature: Date: <br /> F oEvsvcTlanning Application Fonns% Page 7 of 7 <br /> Plan Application AmendmenUm.(Revised 05-11-09 <br />