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Ul � PLAN ° cA MAP AMENDMENT ?{ SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT FILE NUMBER : - - �� oR�' Hazardous Materials Describe any hazardous materials/wastes that will be present on -site : : Other Describe any items of historical or archaeological interest on-site (e . g . cemeteries or structures) : Describe any on-site or off-site sources of noise or vibration (e . g . freeway noise , heavy equipment, etc .) : Describe any on-site or off-site sources of light of glare (e . g . parking lot lighting , or reflective materials used) : Describe any on-site or off-site source of odor (e . g . agricultural wastes) : Describe any displacement of people that will be caused by the project (e . g . numbers of people , housing units) : AUTHORIZATION SIGNATURES ONLY THE OWNER OF THE PROPERTY OR AN AUTHORIZED AGENT MAY FILE AN APPLICATION . I , the Owner/Agent agree , to defend , indemnify , and hold harmless the County and its agents , officers and employees from any claim , action or proceeding against the County arising from the Owner/Agent' s project. I , further, certify under penalty of perjury that I am (check one) : ❑ Legal property owner (owner includes partner, trustee , grantor, or corporate officer) of the property(s ) involved in this application , or Legal agent ( attach proof of the owner' s consent to the application of the property' s involved in this application and have been authorized to file on their behalf. , and that the foregqing foregoingapplication statements are true and correct. Print Name : ` C ��► Signature : Date : Print Name : Signature: Date : Print Name : Signature : Date : Print Name : Signature : Date : Print Name : Si nature . Date : F:\DEVSVC\Planning Application Forms\ Page 7 of 7 Plan Application Amendment. doc. (Revised 06A 1 -09