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4u N PLAN NEAP AMENDMENT y< SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT �4rtco'nt'�p . FILENUMBER: - - Hazardous Materials _ Describe an hazardous materials/wastes that will be present on-site:: None Other Describe any items of historical or archaeological interest on-site(e.g. cemeteries or structures): None Describe any on-site or off-site sources of noise or vibration (e.g.freeway noise, heavy equipment, etc.): None Describe any on-site or off-site sources of light of glare(e.g. parking lot lighting,or reflective materials used): None Describe any on-site or off-site source of odor(e.g. agricultural wastes): None Describe any displacement of people that will be caused by the project(e.g. numbers of people, housing units): None 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 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 VWgoinq applicattiory%aterylients are true and correct. Print Name: Donald R. Lawley Signature: &ItIU4 Date: Print Name: Signature: Date: Print Name: Signature: Date: Print Name: Signature: Date: Print Name: Signature: Date: FADEVSVC\Planning Application Forms\ Page 7 of 7 Plan Application Amendment.doc.(Revised 6-03-04)