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DocuSign Envelope ID : 55CF8235- 1D4A-4FBA-91DD2- F1 CAB 199388E <br /> PLAN MAP AMENDMENT <br /> W< SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> � • . , :P FILE NUMBER : - - <br /> � �/ FORS <br /> Hazardous Materials <br /> Describe any hazardous materials/wastes that will be present on -site : : <br /> None <br /> Other <br /> Describe any items of historical or archaeological interest on -site (e . g . cemeteries or structures ) : <br /> None <br /> Describe any on -site or off-site sources of noise or vibration (e . g . freeway noise , heavy equipment , etc . ) : <br /> Prosect site is 3 /4 of a mile from railroad tracks and 1 mile from California State Hiahway Roue 120 <br /> Describe any on -site or off-site sources of light of glare (e . g . parking lot lighting , or reflective materials used ) : <br /> None <br /> Describe any on -site or off-site source of odor ( e . g . agricultural wastes ) : <br /> None <br /> Describe any displacement of people that will be caused by the project ( e . g . numbers of people , housing units ) : <br /> None <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 /> ® 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 fore i . tion statements are true and correct . <br /> Brittany I_ affe rty �, 5 / 11 / 2021 <br /> Print Name : Signature : Date : <br /> D92FGCD1 DECB492. . . <br /> Print Name : Signature : Date : <br /> Print Name : Signature : Date : <br /> Print Name : Signature : Date : <br /> Print Name : Signature : Date : <br /> F : \DEVSVC\Planning Application Forms\ Page 7 of 7 <br /> Plan Application Amendment . doc . ( Revised 05- 11 - 09 <br />