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PLAN MAP AMENDMENT . <br /> { SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> FILE NUMBER: - -_ <br /> gL�FpR� <br /> Hazardous Materials <br /> Describe any hazardous materials/wastes that will be present on-site:: <br /> X"! <br /> J <br /> Other <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.): <br /> Describe any on-site or off-site sources of light of glare(e.g. parking lot lighting, or reflective materials used): <br /> LWi - <br /> Describe any on-site or off-site source of odor(e.g. agricultural wastes): <br /> ifi <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 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 foregoing application statements are true and correct. <br /> Print Name: Y�-r3r� ll�� >> �f� -�� Signature:` 2_;��,, Date: %S <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> PrintName: Signature: Date: <br /> Print Name. Si nature: Date: <br /> F:\DEVSVC\Planning Application Forms\ Page 8 of 8 <br /> Plan Application Amendment.doc.(Revised 05-11-05 <br />