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opo I" .� SAN JOAQUIN COUNTY N K ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue, Stockton, CA 95205-6232 oP Telephone:(209)468-3420 Fax:(209) 464-0138 Web:www.sjgov.org/ehd SURFACE AND SUBSURFACE CONTAMINATION REPORT REQUIREMENT CHECKLIST [SITE LOCATION: / PA#. r g Dv I q-`I) 10 3� l ��t/yl, REPORT DATE: IyV'L ZQ18 1 - S = Sufficient cSan Joaquin County Development Title Chapter 9-905, Section 9-905.12 e I = Insufficient ufficient S 1 1.0 INTRODUCTION & PROPOSED DEVELOPMENT SECTION ❑ 1.1 Description of site(report must address all parcels), including current and/or proposed zoning information. ❑ 1.2 Description of proposed development. ❑ 1.3 Parcel location map. [t� ❑ 1.4 Site map showing location of all items on parcel. (Examples:structures, drives,wells,septic systems, large trees, pastures, pools, natural drainage courses, ponds, waterways, etc.) 2.0 PAST, PRESENT AND PROPOSED FUTURE USES OF THE SITE SECTION ❑ 2.1 Discussion of past, present and proposed future uses at the site to assess potential problems. (Example sources of information: current and/or previous property owners, historical maps, insurance maps, previous land use applications,etc.) 3.0 IDENTIFICATION OF ALL PAST AND CURRENT SOURCES OF CONTAMINATION [Z( ❑ 3.1 Discussions of the methods used to research and investigate the potential or known above and belowground sources of contamination at the project site. (Examples: Database search, EHD records search,agricultural chemical application search, site reconnaissance and survey,etc.) ❑ 3.2 Description of all past on-site potential and/or known above and below ground sources of contamination identified at the project site. (Examples: Agricultural chemical handling/storage/use, aboveground/underground tanks, septic systems, injection wells, unsealed wells, ponds/lagoons,vehicle/machine repair/painting, buried or stockpiled solid waste,etc.) [/ ❑ 3.3 Description of all current on-site potential and/or known above and below ground sources of contamination identified at the project site(see examples above). ❑ 3.4 Description of all past off-site potential and/or known above and below ground sources of contamination identified in the area of the project site that has or may impact the project site. (Examples: Close proximity to a former landfill/former gasoline station, in area of known DBCP/Nitrate groundwater impact, etc.) qo�(1 ❑ 3.5 Description of all current off-site potential and/or known above and below ground sources of contamination identified in the area of the project site. 4.0 EVALUATION OF PAST AND CURRENT SOURCES OF CONTAMINATIO IDENTIFIED / AT OR NEAR THE SITE AND RECOMMENDATIONS FOR FURTHER ACTION L—d/ ❑ 4.1 Evaluation of each potential and/or known source of contamination identified (in the above section)for any real and/or potential threat to human health and the environment. This evaluation should take into consideration the proposed future uses of the project parcel. 5.0 CONCLUSIONS AND RECOMMENDATIONS SECTION ❑ 5.1 Discussion of the above evaluation to either rule out each source as a real or potential threat or to recommend further action to mitigate or abate any real or potential threats identified. Recommendations may include additional site assessment(i.e. collection of soillwater samples)and/or mitigative measures (i.e.,clean up of surface wastes). All recommendations for future work must include a time frame for implementation. L^y{ ❑ 5.2 The report was inclusive(i.e.all information referenced was included in this report-report should not reference other reports). ❑ 5.3 The report was signed, dated and stamped by a qualified environmental professional. Ld ❑ 5.4 The report was prepared within six months of the date of the submittal of the land use application. El ❑ 5.5 The att chmen a pendices contain s fficie t documentation to support claims made in report. Reviewed By: 1A Reviewed Date: EHD 26-014124112 Page rof 2 SURFACE&SUB CKLST