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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton, CA 95202-3029 Telephone:(209)468-3420 Fax:(209)464-01.38 Web:www.sigov.org/ehd SURFACE AND SUBSURFACE CONTAMINATION REPORT REQUIREMENT CHECKLIST SITE Locmiow + �J / �• � PA#: Q IF_Q+v1Z ,. s ` + U�8 / ! 1/�y� I REPORT DATE: S = sufficient San Joaquin County Development Title Chapter 9-905,Section 9-905.12 I = Insufficient S I 9.0 INTRODUCTION & PROPOSED DEVELOPMENT SECTION ❑ 1.1 Des ription of site,(report must address all parcels), including current and/or proposed zoning information. Fgf ❑ 1.2 Des tion 64proposeddevelopment. ❑ 1.3 Parcel loon rapp. } ® ❑ 1.4 Site map wi�ntgqdcat�on of all items on parcel. (Examples:structures, drives,wells, septic systems,large trees, pastures, pools,natural drainage courses, ponds,waterways,etc.) 2,0 PAST,, =3EZT AND PROPOSED FUTURE USES OF THE SITE SECTION M ❑ 2.1 Discussion of past,present and proposed future uses at the site to assess potential problems. (Example sources of information:currenntt�nd/or previous property owners,historical maps, insurance maps, previous land use applications,etc. 3.0 IDENTIFICATION OF ALL PAST AND CURRENT SOURCES OF CONTAMINATION IN ❑ 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 applica' �rcf,site reconnaissance and survey,etc.)3.2 Description of a pas� site potential and/or known above and below ground sources of contamination identified at the project site. (Examples: Agricultural chemical handling/storage/use,abovegroundlunderground tanks, septic systems, injection well sLu�n Baled wells,pondsllagoons,vehiclelmachine repair/painting, buried or stockpiled solid waste,etc.) ® ❑ 3.3 Description of all current on- ite potential and/or known above and below ground sources of contamination identified at the proj�sio?(see examples above). f. E] 3.4 Description of all pa h``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: Gose proximity to a former landfill/former gasoline station, i sea*in5wn DBCP/Nitrate groundwater impact,etc.) 4� ❑ 3.5 Description of all current off-site n ndlor known above and below ground sources of contamination identified in the area of the project site. �� 4.0 EVALUATION OF PAST AND CUR NT SOURCES OF CONTAMINATION IDENTIFIED 4 AT OR NEAR THE SITE AND RECOMMENDATIONS FOR FURTHER ACTION R] ❑ 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 environment. This evaluation should take into consideration the proposed future uses of the project parcel. �1 5.0 CONCLUSIONS AND RECOMME DATIONS SECTION o� ❑ 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 soil/water samples)and/or mitigative measures(i.e.,clean up of surface wastes). Allgcom�mendations for future work must include a time frame for implementation. { ❑ 5.2 The report was inclusio(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. [�-- ❑ 5.4 The report was prepared within six months of the date of the submittal of the land use application. ❑ 5.5 The attachmen appendices contain sufficient documentation to support claims made in report. Reviewed By: IMP Reviewed Date: EHD 26-01 Pagel of 2 surface&sub Checklist ,Il AI'l,ll1]