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SAN JOAQUIN COUNTY ENV 1RONMENTAL HEALTH DEPARTNtvNT 600 East Main Street, Stockton, CA 95202-3029 Telephone: (209)468-3420 Fax:(209)464-0138 Web:www.sigov.org/ehd SURFACE AND SUBSURFACE CONTAMINATION REPORT REQUIREMENT CHECKLIST SITE LOCATION: q t PA#: 1 U --420 16 7 M s) �� SjI`f.�1+�1►� Ave, C—.S c�vt REPORT DATE: s = Sufficient San Joaquin County Development Title Chapter 9-905,Section 9-905.12 I = Insufficient S 1 1.0 INTRODUCTION & PROPOSED DEVELOPMENT SECTION ❑ 1.1 Description rof site(report must address all parcels), including current and/or proposed zoning information. ® ❑ 1.2 Description of proposed development. I ® ❑ 1.3 Parcel location map. Arr*,� ® ❑ 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 ® ❑ 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.) to / ®, ❑ 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.) rj — PS ❑ 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). HJ ❑ 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: Gose proximity to a former landfill/former gasoline station, in area of known DBCP/Nitrate groundwater impact,etc.) IC] ❑ 3.5 Description of all current off-site potential and/� own above and below ground sources of contamination identified in the area of the project site. 13 i 4.o 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. ❑ 5.2 The report was inclus&'(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. EF ❑ 5.5 The attachments/appendices contain sufficient documentation to support claims made in report. Reviewed By: r,11"S w730as Reviewed Date: v EM 25.01 Page 1 of 2 surface&sub checklist 11.a M-1