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�� X,6, SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT big 600 East Main Street, Stockton, CA 95202-3029 Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd cT7,77 ' SURFACE AND SUBSURFACE CONTAMINATION REPORT REQUIREMENT CHECKLIST SITE LOCATION: N cJ-j I 1 .2 PAM - 00o S4 AAS� REPORTDATE: 8 19 —1.3 S = sufficirnc I = Insufficirnt San Joaquin County Development Title Chapter 9-905, Section 9-905.12 S I 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 Description64proposed development. as L �] ❑ 1.3 Parcel location map. Afr—A - ❑ 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.) p eev.'.1 2.0 PAST, PRESENT All "' 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.) 1. 1 — ? 3.0 IDENTIFICATION OF ALL PAST AND CURRENT SOURCES OF CONTAMINATION ❑ 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.) 65 �. -9 ❑ 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.) CS 5— I Z [] ❑ 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). I_ ,z ❑ 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.) t. ❑ 3.5 Description of all current off-site potential and/or nown above and below ground sources of contamination identified in the area of the project site. 7-12- 4.0 _1L4.0 EVALUATION OF PAST AND CURRENT SOURCES OF CONTAMINATION IDENTIFIED AT OR NEAR THE SITE AND RECOMMENDATIONS FOR FURTHER ACTION ® ❑ 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 soil/water samples)and/or mitigative measures (i.e., clean up of surface wastes). All recommendations for future work must include a time frame for implementation. C, k3 Q ❑ 5.2 The report was inclusive g.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. 0 ❑ 5.4 The report was prepared within six months of the date of the submittal of the land use application. B ❑ 5.5 The attachments/appendices contain sufficient documentation to support claims made in report. Reviewed By: ZA III u o. — Reviewed Date: EHD 26-01 Page I of 2 Surface&Sub Checklist