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DocuSign Envelope ID:55CF8235-1D4A-4FBA-9DD2-F1 CAB 199388E <br /> PLAN MAP AMENDMENT <br /> N � < SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> • �•., �P FILE NUMBER: - <br /> ��%PORE <br /> Hazardous Materials <br /> Describe any hazardous materials/wastes that will be present on-site:: <br /> None <br /> Other <br /> Describe any items of historical or archaeological interest on-site (e.g.cemeteries or structures): <br /> None <br /> Describe any on-site or off-site sources of noise or vibration (e.g.freeway noise, heavy equipment,etc.): <br /> Proiect_site is3/4 of a mile from railroad tracks and 1 mile from California State Hiahway Route 120 <br /> Describe any on-site or off-site sources of light of glare(e.g. parking lot lighting, or reflective materials used): <br /> None <br /> Describe any on-site or off-site source of odor(e.g.agricultural wastes): <br /> None <br /> Describe any displacement of people that will be caused by the project(e.g. numbers of people, housing units): <br /> None <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 foregaibg„apWi :tion statements are true and correct. <br /> Brittany Lafferty 5/11/2021 <br /> Print Name: Signature: Date: <br /> D92F6CD 1 DEC8492... <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 05-11-09 <br />