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PLAN VAP AMENDMENT , <br /> W. Zi SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> - - <br /> FILE NUMBER: , <br /> Describe an hazardous materialslwastes that will be resert't:on-site:z A-K ✓W I e <br /> 'ti a kal�,� ns S.4h •i - r i i�*y. � s..n.-}�i S'':S�""rn;�,,i.f,�'.A:.t-�+mgir� .w>Vrrx F� k���3i 45 f� � i t-, r �rx P� k, 1 i .��� <br /> - <br /> ' <br /> C <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.): r, �,, 01" <br /> Describe any on-site or off-site sources of light of glare(e.g.parking lot lighting,or reflective materials used): <br /> Describe any on-site or off-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 Owner/Agents project. <br /> I,further, certify under penalty of perjury that I am (check one): <br /> "Legal property owner (owner includes partner, trustee, grant r, corporate officer)of the property(s) involved in <br /> this application, or <br /> ❑ Legal agent(attach proof of the owner's consent to the ap tion of the property's involved in this application and <br /> have been authorized to file on their behalf., and that the f goingapplication statements are true and correct. <br /> Print Name: S7rryle �+Ftb1 Signature: Date: Z b <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Si nature: Date: <br /> R:DPVSVCIPlanningApplication FormM Page 7 of 7 <br /> Plan Application Amendment.doc.(Revised 6-03-04) <br />