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PA2200266 , <br /> i <br /> 1, the Owner/Agent agree, toefend, indemnify, and hold harmless the County and its agents, officers and <br /> employees from any claim, ac ion or proceeding against the County arising from the Owner/Agent's project. <br /> I,further,.certify under penal ! of perjury that I am (check one): <br /> 4 <br /> Legal property owner(o i ner includes partner, trustee, trustor, or corporate officer) of the property(s) t <br /> involved in this applicati+aCy, or <br /> ❑ Legal agent(attach pro of the owner's consent to the application of the property's involved in this <br /> application and have been a harized to file on their behalf., and that the foregoing application statements <br /> are true and correct <br /> I <br /> Print Name: Robert Brown. �- Signature: <br /> i Date _/—;Z <br /> Print Name: I� signature: Date: <br /> Print Name. i Signature: Date: <br /> Print Name' Signature; Date: <br /> I <br /> Print Name: Signature: Date: <br /> i <br /> j I'VEVS"ianning Appkadon Fors We Appr�val,(Revised W-03-19) Page 5 of 8 <br /> i <br /> San Joa uin County <br /> y <br /> p'.14 IV f. C DIRECTOR i <br /> aG Envir nmelntal Health Department Donna Haran,REHS <br /> 1 868 E i <br /> - azetton Avenue GROGRAM COORDINATORS <br /> Stockton, California 95205 Robert McClellan,REHS <br /> Jeff Carrue=,REHS,Rol <br /> p Kasey Foley,REHS t <br /> - Linda Turkatte,REHS 1 <br /> Websits: www.s]gov,orgle d Rodney Estrada,REHs ; <br /> Adrienne Eiisaessar,REHS s <br /> Phone: (205)45$-3420 t <br /> I Fax- (209)458-3433 } <br /> HAZARDOUS MATERIALS DISCLOSURE SURVEY <br /> c <br /> A separate surve I form Is required for each business name and/or address in San Joaquin County., 1 <br /> Business Name: L� �� 1 i Telephone: <br /> Business Site Address: (k), 0,<SdA 1 Q o t-A <br /> Mailing Address(if different frorri above): <br /> Business Owner(s)Name:ti.J 'T w i AS Te one: <br /> i <br /> `- � <br /> Business Owner Address: <br /> Nature of Business. Fire District zndtdfir" (4 — L ±Thivy�. <br /> i <br /> R1, RlYes fl No � Does your business handle a hazardous material In any quantity at any one bme in the year? ; <br /> See the definition of hazardous material on page 2 of this form. <br /> 0 Yes ❑No Does your business generate,treat,or store a hazardous waste in any tivantltO (used oil, 1 <br /> used antifreeze,waste solvent,etc.) <br /> i <br />