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PQ�tN PLAN MAP AMENDMENT i <br /> r 'G <br /> a < SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> FILE NUMBER: - <br /> ,C.i <br /> Hazardous Materials <br /> Describe anyhazardous materials/wastes that will be present on-site:: <br /> Other <br /> Describe any items of historical or archaeological interest on-site (e.g. cemeteries or structures): <br /> lLQ, <br /> Describe any on-site or off-site sources of noise or vibration(e.g.freeway noise,heavy equipment, etc.): <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/Agent's project. <br /> I, further, certify under penalty of perjury that I am (check one): <br /> M11"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 foregoing a lication atements are true and correct. <br /> Print Name: /�r � �Gf r� Signature: Date: 119 <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 6-03-04) <br />